=====================================================
General NPI Number Information
=====================================================
NPI Number | 1245170885
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | JOURNEYCARE MEDICAL
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/01/2026
-----------------------------------------------------
Last Update Date | 04/01/2026
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 350 W WOODROW WILSON AVE STE 3010
-----------------------------------------------------
City | JACKSON
-----------------------------------------------------
State | MS
-----------------------------------------------------
Zip | 39213-7681
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 601-376-8019
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1023 WINDMILL DR
-----------------------------------------------------
City | BYRAM
-----------------------------------------------------
State | MS
-----------------------------------------------------
Zip | 39272-4469
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 601-376-8019
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CEO/MEDICAL DIRECTOR
-----------------------------------------------------
Name | DR. SHANTRICE BERNICE NICHOLS-BATES
-----------------------------------------------------
Credential | DNP
-----------------------------------------------------
Telephone | 601-376-8019
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363LP2300X
-----------------------------------------------------
Taxonomy Name | Primary Care Nurse Practitioner
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------