Healthcare Provider Details

I. General information

NPI: 1174755359
Provider Name (Legal Business Name): INNOVATIVE HEALTH LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/20/2009
Last Update Date: 01/17/2020
Certification Date: 01/17/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

501 MARSHALL ST STE 605
JACKSON MS
39202-1650
US

IV. Provider business mailing address

501 MARSHALL ST STE 605
JACKSON MS
39202-1650
US

V. Phone/Fax

Practice location:
  • Phone: 601-968-1690
  • Fax: 601-968-1693
Mailing address:
  • Phone: 601-968-1690
  • Fax: 601-968-1693

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LX0001X
TaxonomyObstetrics & Gynecology Nurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: MARIE J WILLIAMS
Title or Position: OWNER/CEO
Credential: NP
Phone: 601-968-1690