Healthcare Provider Details

I. General information

NPI: 1669974317
Provider Name (Legal Business Name): MEMPHIS FAMILY CONNECTION CENTER , LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/07/2018
Last Update Date: 02/05/2025
Certification Date: 02/05/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

815 N MCLEAN BLVD
MEMPHIS TN
38107-4608
US

IV. Provider business mailing address

815 N MCLEAN BLVD
MEMPHIS TN
38107-4608
US

V. Phone/Fax

Practice location:
  • Phone: 901-614-1902
  • Fax:
Mailing address:
  • Phone: 901-614-1902
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number
License Number State
# 4
Primary TaxonomyY
Taxonomy Code261Q00000X
TaxonomyClinic/Center
License Number
License Number State

VIII. Authorized Official

Name: JAMIE CHESSOR
Title or Position: BILLING MANAGER
Credential:
Phone: 901-614-1902