Healthcare Provider Details

I. General information

NPI: 1689664765
Provider Name (Legal Business Name): CLC OF JACKSON, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/28/2005
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1600 RAYMOND RD
JACKSON MS
39204-4203
US

IV. Provider business mailing address

1600 RAYMOND RD
JACKSON MS
39204-4203
US

V. Phone/Fax

Practice location:
  • Phone: 601-371-1700
  • Fax: 601-371-1006
Mailing address:
  • Phone: 601-371-1700
  • Fax: 601-371-1006

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number612
License Number StateMS

VIII. Authorized Official

Name: MR. DOUGLAS M. WRIGHT JR.
Title or Position: MANAGING MEMBER
Credential:
Phone: 662-680-3148