Healthcare Provider Details

I. General information

NPI: 1659527414
Provider Name (Legal Business Name): JACKSON PUBLIC SCHOOLS CLAUSELL CLINIC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/13/2008
Last Update Date: 08/13/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

618 S PRESIDENT ST
JACKSON MS
39201-5601
US

IV. Provider business mailing address

3330 HARLEY ST
JACKSON MS
39209-7239
US

V. Phone/Fax

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

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163WS0200X
TaxonomySchool Registered Nurse
License NumberR557579
License Number StateMS
# 2
Primary TaxonomyY
Taxonomy Code261QS1000X
TaxonomyStudent Health Clinic/Center
License Number
License Number State

VIII. Authorized Official

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