Healthcare Provider Details

I. General information

NPI: 1407069321
Provider Name (Legal Business Name): MARK BALDWIN LPC-MHSP
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/07/2007
Last Update Date: 03/03/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

575 S ROYAL ST SUITE 24
JACKSON TN
38301-7307
US

IV. Provider business mailing address

75 HOLIDAY DR
JACKSON TN
38305-3716
US

V. Phone/Fax

Practice location:
  • Phone: 731-467-0504
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number1878
License Number StateTN
# 2
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number1878
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: