Healthcare Provider Details

I. General information

NPI: 1710366273
Provider Name (Legal Business Name): MISSISSIPPI CHILDREN'S HOME SOCIETY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/29/2015
Last Update Date: 05/29/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1465 LAKELAND DR
JACKSON MS
39216-4719
US

IV. Provider business mailing address

1465 LAKELAND DR
JACKSON MS
39216-4719
US

V. Phone/Fax

Practice location:
  • Phone: 601-352-7784
  • Fax: 601-968-0021
Mailing address:
  • Phone: 601-352-7784
  • Fax: 601-968-0021

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code322D00000X
TaxonomyEmotionally Disturbed Childrens' Residential Treatment Facility
License Number
License Number State

VIII. Authorized Official

Name: DR. JOHN D DAMON
Title or Position: CHIEF EXECUTIVE OFFICER
Credential: PH.D.
Phone: 601-352-7784