Healthcare Provider Details

I. General information

NPI: 1063373587
Provider Name (Legal Business Name): MISS TIONNA ALEXIS TINA ANDERSON
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/24/2025
Last Update Date: 12/01/2025
Certification Date: 12/01/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2500 N STATE ST
JACKSON MS
39216-4500
US

IV. Provider business mailing address

130 SWAN LAKE CV
JACKSON MS
39212-5332
US

V. Phone/Fax

Practice location:
  • Phone: 601-984-1000
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License NumberS-5375
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: