Healthcare Provider Details

I. General information

NPI: 1952839409
Provider Name (Legal Business Name): MAGNOLIA COUNSELING CENTER & SERVICES, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/29/2017
Last Update Date: 02/11/2020
Certification Date: 02/11/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2130 GOVERNMENT ST STE A
OCEAN SPRINGS MS
39564-3937
US

IV. Provider business mailing address

2130 GOVERNMENT ST STE A
OCEAN SPRINGS MS
39564-3937
US

V. Phone/Fax

Practice location:
  • Phone: 228-382-3107
  • Fax: 800-854-0906
Mailing address:
  • Phone: 228-382-3107
  • Fax: 800-854-0906

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QM0855X
TaxonomyAdolescent and Children Mental Health Clinic/Center
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number
License Number State

VIII. Authorized Official

Name: JESSICA ELLEN ROBERTSON
Title or Position: OWNER
Credential:
Phone: 228-382-3107