Healthcare Provider Details

I. General information

NPI: 1548342611
Provider Name (Legal Business Name): CENTRAL MISSISSIPPI CIVIC IMPROVEMENT ASSOCIATION, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/19/2006
Last Update Date: 01/26/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3502 W NORTHSIDE DR
JACKSON MS
39213-4454
US

IV. Provider business mailing address

3502 W NORTHSIDE DR
JACKSON MS
39213-4454
US

V. Phone/Fax

Practice location:
  • Phone: 601-362-5321
  • Fax: 601-364-2600
Mailing address:
  • Phone: 601-362-5321
  • Fax: 601-364-2600

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code333600000X
TaxonomyPharmacy
License Number0081704.5
License Number StateMS

VIII. Authorized Official

Name: DR. JASMIN CHAPMAN
Title or Position: CEO
Credential: D.D.S
Phone: 601-362-5321