Healthcare Provider Details

I. General information

NPI: 1366898025
Provider Name (Legal Business Name): LEMICHAL DRAKE CCRP
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/11/2016
Last Update Date: 08/27/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5773 OLD CANTON RD
JACKSON MS
39211-3202
US

IV. Provider business mailing address

5773 OLD CANTON RD
JACKSON MS
39211-3202
US

V. Phone/Fax

Practice location:
  • Phone: 601-994-4647
  • Fax:
Mailing address:
  • Phone: 601-994-4647
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code174H00000X
TaxonomyHealth Educator
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code172V00000X
TaxonomyCommunity Health Worker
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: