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General NPI Number Information
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NPI Number | 1043573199
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Entity Type | Organization
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Legal Business Name | FONDREN MEDICAL CLINIC
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Dates
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Enumeration Date | 06/22/2012
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Last Update Date | 06/22/2012
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Provider Practice Location Address
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Address Line | 4436 N STATE ST SUITE A-1
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City | JACKSON
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State | MS
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Zip | 39206-5334
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Country | US
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Telephone | 769-257-5339
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Fax |
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Provider Business Mailing Address
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Address Line | 4436 N STATE ST SUITE A-1
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City | JACKSON
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State | MS
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Zip | 39206-5334
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Country | US
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Telephone | 769-257-5339
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Fax |
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Authorized Official
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Title or Position | PHYSICIAN/OWNER
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Name | DR. THERESA LEIJUAN LANE-FISHER
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Credential | P.H,D,PA
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Telephone | 769-257-5336
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QP2300X
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Taxonomy Name | Primary Care Clinic/Center
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License Number |
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License Number State |
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