Healthcare Provider Details

I. General information

NPI: 1518140599
Provider Name (Legal Business Name): JACKSON PUBLIC SCHOOLS MCWILLIE CLINIC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/12/2007
Last Update Date: 12/12/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4851 MCWILLIE CIR
JACKSON MS
39206-5025
US

IV. Provider business mailing address

618 S PRESIDENT ST
JACKSON MS
39201-5601
US

V. Phone/Fax

Practice location:
  • Phone: 601-209-4456
  • Fax: 601-960-8704
Mailing address:
  • Phone: 601-960-8705
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261Q00000X
TaxonomyClinic/Center
License Number
License Number State

VIII. Authorized Official

Name: MRS. TAMMY D CROCKER
Title or Position: LEAD NURSE
Credential: R.N.
Phone: 601-209-4456