Healthcare Provider Details

I. General information

NPI: 1215657937
Provider Name (Legal Business Name): PREMIER CHOICE BEHAVIORAL HEALTH AND WELLNESS CLINIC, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/01/2022
Last Update Date: 10/03/2022
Certification Date: 10/03/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1832 HOSPITAL DR
JACKSON MS
39204-3410
US

IV. Provider business mailing address

PO BOX 59147
JACKSON MS
39284-9147
US

V. Phone/Fax

Practice location:
  • Phone: 601-371-8883
  • Fax: 866-272-5766
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code261QM0855X
TaxonomyAdolescent and Children Mental Health Clinic/Center
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code261QM1300X
TaxonomyMulti-Specialty Clinic/Center
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code261QP2300X
TaxonomyPrimary Care Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: MRS. KIMBERLY CARSON
Title or Position: FNP
Credential: FNP-BC
Phone: 601-218-0969