Healthcare Provider Details

I. General information

NPI: 1780059402
Provider Name (Legal Business Name): RACHEL TYRONE
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/07/2015
Last Update Date: 04/21/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2500 NORTH STATE STREET
JACKSON MS
39216-4500
US

IV. Provider business mailing address

2500 NORTH STATE STREET JMM ROOM 2525
JACKSON MS
39216-4500
US

V. Phone/Fax

Practice location:
  • Phone: 601-815-4969
  • Fax: 601-984-1531
Mailing address:
  • Phone: 601-984-6426
  • Fax: 601-984-6439

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: