Healthcare Provider Details

I. General information

NPI: 1629400916
Provider Name (Legal Business Name): LAKISHA NICHOLS COLEMAN SLP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/08/2013
Last Update Date: 05/04/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

249 PEARLIE OWENS DR
JACKSON MS
39212-3273
US

IV. Provider business mailing address

249 PEARLIE OWENS DR
JACKSON MS
39212-3273
US

V. Phone/Fax

Practice location:
  • Phone: 601-597-0681
  • Fax:
Mailing address:
  • Phone: 601-597-0681
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License NumberS3659
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: