Healthcare Provider Details

I. General information

NPI: 1902025752
Provider Name (Legal Business Name): THE CHILDREN'S CLINIC, PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/24/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1513 LAKELAND DR SUITE 101
JACKSON MS
39216-4829
US

IV. Provider business mailing address

1513 LAKELAND DR SUITE 101
JACKSON MS
39216-4829
US

V. Phone/Fax

Practice location:
  • Phone: 601-362-8233
  • Fax: 601-362-8237
Mailing address:
  • Phone: 601-362-8233
  • Fax: 601-362-8237

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number
License Number State

VIII. Authorized Official

Name: MRS. SHEILA M. HARKINS
Title or Position: OFFICE MANAGER
Credential: CMPE
Phone: 601-362-8233