Healthcare Provider Details

I. General information

NPI: 1568598027
Provider Name (Legal Business Name): ERICKA M MICOU NP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/26/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1134 WINTER ST
JACKSON MS
39204-2841
US

IV. Provider business mailing address

1134 WINTER ST
JACKSON MS
39204-2841
US

V. Phone/Fax

Practice location:
  • Phone: 601-948-5572
  • Fax: 601-914-3012
Mailing address:
  • Phone: 601-948-5572
  • Fax: 601-914-3012

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LC1500X
TaxonomyCommunity Health Nurse Practitioner
License Number363L00000X
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: