Healthcare Provider Details

I. General information

NPI: 1235776089
Provider Name (Legal Business Name): MIRIAM DENISE JACKSON-HAMILTON LPC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: MIRIAM DENISE JACKSON LPC

II. Dates (important events)

Enumeration Date: 11/27/2019
Last Update Date: 11/27/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

159 PARKWAY AVE
ROLLING FORK MS
39159-5112
US

IV. Provider business mailing address

159 PARKWAY AVE
ROLLING FORK MS
39159-5112
US

V. Phone/Fax

Practice location:
  • Phone: 662-907-1906
  • Fax:
Mailing address:
  • Phone: 662-907-1906
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number2303
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: