=====================================================
General NPI Number Information
=====================================================
NPI Number | 1134770415
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JOHN JOSEPH FERNANDEZ PAJARILLAGA P-LPC, CCSS, CADC
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/26/2019
-----------------------------------------------------
Last Update Date | 05/21/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 141 TOWNSHIP AVE STE 303
-----------------------------------------------------
City | RIDGELAND
-----------------------------------------------------
State | MS
-----------------------------------------------------
Zip | 39157-8699
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 601-790-0083
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4325 MEADOWRIDGE DR
-----------------------------------------------------
City | JACKSON
-----------------------------------------------------
State | MS
-----------------------------------------------------
Zip | 39206-5912
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 216-406-6741
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YP2500X
-----------------------------------------------------
Taxonomy Name | Professional Counselor
-----------------------------------------------------
License Number | 2876
-----------------------------------------------------
License Number State | MS
-----------------------------------------------------