=====================================================
General NPI Number Information
=====================================================
NPI Number | 1497200570
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | FAMILY CONNECTIONS COUNSELING CENTER LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/18/2016
-----------------------------------------------------
Last Update Date | 08/18/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 418 LIBERTY RD
-----------------------------------------------------
City | NATCHEZ
-----------------------------------------------------
State | MS
-----------------------------------------------------
Zip | 39120-4314
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 601-434-2977
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 418 LIBERTY RD
-----------------------------------------------------
City | NATCHEZ
-----------------------------------------------------
State | MS
-----------------------------------------------------
Zip | 39120-4314
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 601-434-2977
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | ADMINISTRATOR
-----------------------------------------------------
Name | MS. JESSIE LUSTER SINGLETON
-----------------------------------------------------
Credential | LCSW
-----------------------------------------------------
Telephone | 601-434-2977
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1041C0700X
-----------------------------------------------------
Taxonomy Name | Clinical Social Worker
-----------------------------------------------------
License Number | C5919
-----------------------------------------------------
License Number State | MS
-----------------------------------------------------