Healthcare Provider Details

I. General information

NPI: 1376152512
Provider Name (Legal Business Name): JACKSON MS HOMECARE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/23/2020
Last Update Date: 11/17/2023
Certification Date: 11/17/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2625 RIDGEWOOD RD STE 104
JACKSON MS
39216-4900
US

IV. Provider business mailing address

2625 RIDGEWOOD RD STE 104
JACKSON MS
39216-4900
US

V. Phone/Fax

Practice location:
  • Phone: 601-500-5027
  • Fax: 601-500-7344
Mailing address:
  • Phone: 601-500-5027
  • Fax: 601-500-7344

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code253Z00000X
TaxonomyIn Home Supportive Care Agency
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code374U00000X
TaxonomyHome Health Aide
License Number
License Number State

VIII. Authorized Official

Name: CLIFTON REESE DANIELS
Title or Position: EXECUTIVE DIRECTOR
Credential:
Phone: 601-500-5027