Healthcare Provider Details

I. General information

NPI: 1467862870
Provider Name (Legal Business Name): MISSISSIPPI STATE DEPARTMENT OF HEALTH
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/07/2014
Last Update Date: 05/07/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

350 W WOODROW WILSON AVE SUITE 411 A
JACKSON MS
39213-7681
US

IV. Provider business mailing address

570 E WOODROW WILSON AVE
JACKSON MS
39216-4538
US

V. Phone/Fax

Practice location:
  • Phone: 601-364-2666
  • Fax: 601-364-2659
Mailing address:
  • Phone: 601-576-7635
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251K00000X
TaxonomyPublic Health or Welfare Agency
License Number
License Number State

VIII. Authorized Official

Name: MR. MITCHELL ADCOCK
Title or Position: CHIEF ADMINISTRATIVE OFFICER
Credential: CAO
Phone: 601-576-7635