Healthcare Provider Details

I. General information

NPI: 1588846281
Provider Name (Legal Business Name): BEHAVIORAL MEDICINE CLINIC,PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/04/2007
Last Update Date: 06/01/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5000 HWY 39 N
MERIDIAN MS
39301-1021
US

IV. Provider business mailing address

5000 HWY 39 N
MERIDIAN MS
39301-1021
US

V. Phone/Fax

Practice location:
  • Phone: 601-482-2400
  • Fax:
Mailing address:
  • Phone: 601-482-2400
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TP0016X
TaxonomyPrescribing (Medical) Psychologist
License Number14095
License Number StateMS

VIII. Authorized Official

Name: DR. TERRY JORDAN
Title or Position: OWNER
Credential: M.M.
Phone: 601-482-2400