MEDICARE: CENTRAL MISSISSIPPI CIVIC IMPROVEMENT ASSOCIATION, INC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	261QF0400X	Federally Qualified Health Center (FQHC)

General Provider Information

NPI Number	:	1447448667
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CENTRAL MISSISSIPPI CIVIC IMPROVEMENT ASSOCIATION, INC

Provider Business Mailing Address
First Line	:	3502 W NORTHSIDE DR
Second Line	:
City	:	JACKSON
State	:	MS
Zip	:	39213-4454
Country	:	US
Telephone Number	:	601-362-5321
Fax Number	:	601-364-2600

Provider Business Practice Location Address
First Line	:	2185 FORTUNE ST
Second Line	:
City	:	JACKSON
State	:	MS
Zip	:	39204-2333
Country	:	US
Telephone Number	:	601-960-5354
Fax Number	:	601-360-2625

Authorized Official
Title or Position	:	CEO
Name	:	DR. JASMIN R CHAPMAN
Credential	:	DDS
Telephone Number	:	601-362-5321

Provider Enumeration Date	:	10/12/2007
Last Update Date	:	01/29/2021

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