Healthcare Provider Details

I. General information

NPI: 1245170885
Provider Name (Legal Business Name): JOURNEYCARE MEDICAL
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/01/2026
Last Update Date: 04/01/2026
Certification Date: 04/01/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

350 W WOODROW WILSON AVE STE 3010
JACKSON MS
39213-7681
US

IV. Provider business mailing address

1023 WINDMILL DR
BYRAM MS
39272-4469
US

V. Phone/Fax

Practice location:
  • Phone: 601-376-8019
  • Fax:
Mailing address:
  • Phone: 601-376-8019
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP2300X
TaxonomyPrimary Care Nurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: DR. SHANTRICE BERNICE NICHOLS-BATES
Title or Position: CEO/MEDICAL DIRECTOR
Credential: DNP
Phone: 601-376-8019