Healthcare Provider Details

I. General information

NPI: 1194536425
Provider Name (Legal Business Name): SECOND CHANCE HEALTH & WELLNESS LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/16/2025
Last Update Date: 01/16/2025
Certification Date: 01/16/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11 NORTHTOWN DR STE 225
JACKSON MS
39211-3698
US

IV. Provider business mailing address

15 OAKFORD CT
JACKSON MS
39211-3050
US

V. Phone/Fax

Practice location:
  • Phone: 601-842-4718
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QF0050X
TaxonomyNon-Surgical Family Planning Clinic/Center
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QH0100X
TaxonomyHealth Service Clinic/Center
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code261QS1000X
TaxonomyStudent Health Clinic/Center
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code251300000X
TaxonomyLocal Education Agency (LEA)
License Number
License Number State
# 6
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State
# 7
Primary TaxonomyY
Taxonomy Code261QC1500X
TaxonomyCommunity Health Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: DEVIN FOSTER
Title or Position: CEC/FOUNDER
Credential:
Phone: 601-842-4718