Healthcare Provider Details

I. General information

NPI: 1891262374
Provider Name (Legal Business Name): MRS. MARY KATHRYN EVANS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/01/2018
Last Update Date: 11/01/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

199 CHARMANT PL STE 1
RIDGELAND MS
39157-4358
US

IV. Provider business mailing address

1404 SAINT ANN ST
JACKSON MS
39202-1846
US

V. Phone/Fax

Practice location:
  • Phone: 601-850-7047
  • Fax:
Mailing address:
  • Phone: 601-506-0528
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: