MEDICARE: KEYSTONE COUNSELING, PLLC

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	101YP2500X	Professional Counselor	1544	MS

General Provider Information

NPI Number	:	1871994368
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	KEYSTONE COUNSELING, PLLC

Provider Business Mailing Address
First Line	:	1755 LELIA DR
Second Line	:	SUITE 105
City	:	JACKSON
State	:	MS
Zip	:	39216-4828
Country	:	US
Telephone Number	:	601-790-0749
Fax Number	:

Provider Business Practice Location Address
First Line	:	1755 LELIA DR
Second Line	:	SUITE 105
City	:	JACKSON
State	:	MS
Zip	:	39216-4828
Country	:	US
Telephone Number	:	601-790-0749
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	JAMES L ROBERSON III
Credential	:	LPC
Telephone Number	:	601-919-7578

Provider Enumeration Date	:	09/15/2014
Last Update Date	:	09/15/2014

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