Healthcare Provider Details

I. General information

NPI: 1922817212
Provider Name (Legal Business Name): LAUREN JACKSON
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/02/2025
Last Update Date: 01/02/2025
Certification Date: 01/02/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4013 BEATLINE RD
LONG BEACH MS
39560-4135
US

IV. Provider business mailing address

4013 BEATLINE RD
LONG BEACH MS
39560-4135
US

V. Phone/Fax

Practice location:
  • Phone: 228-200-0720
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License NumberP-1140
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: