MEDICARE: LEGACY 4 CHANGE

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	1041C0700X	Clinical Social Worker

General Provider Information

NPI Number	:	1912664509
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	LEGACY 4 CHANGE

Provider Business Mailing Address
First Line	:	PO BOX 821878
Second Line	:
City	:	VICKSBURG
State	:	MS
Zip	:	39182-1878
Country	:	US
Telephone Number	:	769-203-8141
Fax Number	:

Provider Business Practice Location Address
First Line	:	2891 TERRY RD
Second Line	:
City	:	JACKSON
State	:	MS
Zip	:	39212-3051
Country	:	US
Telephone Number	:	769-203-8141
Fax Number	:

Authorized Official
Title or Position	:	PRESIDENT
Name	:	CHASITY DAVIS
Credential	:
Telephone Number	:	769-203-8141

Provider Enumeration Date	:	11/18/2021
Last Update Date	:	01/20/2022

Similar Medicare Providers

1598797532 — FREDS STORES OF TENNESSEE INC
Practice Location Address:

2885 TERRY RD
JACKSON, MS
39212-3051

Practice Phone: 601-373-6783
Practice Fax: 601-371-9137

1205909777 — BROOKSHIRE GROCERY COMPANY
Practice Location Address:

2861 TERRY RD , ATTENTION PHARMACY DEPT
JACKSON, MS
39212-3051

Practice Phone: 601-372-2387
Practice Fax: 601-372-0369

1265559496 — LEIGH TANYA WALKER DMD
Practice Location Address:

2891 TERRY RD
JACKSON, MS
39212-3051

Practice Phone: 601-371-1157
Practice Fax:

1588972004 — DR. BETTINA J. ADAMS PHARM.D.
Practice Location Address:

2885 TERRY RD
JACKSON, MS
39212-3051

Practice Phone: 601-373-6783
Practice Fax: 601-371-9137

1134072309 — FAYA THERAPY LLC
Practice Location Address:

1121 JACKSON ST NE STE 100
MINNEAPOLIS, MN
55413-3051

Practice Phone: 612-293-7353
Practice Fax:

1164472866 — WAVERLEY HEALTH CARE CONSULTANTS, INC.
Practice Location Address:

460 BRIARWOOD DR , SUITE 410
JACKSON, MS
39206-3051

Practice Phone: 601-956-1576
Practice Fax:

Directions to “LEGACY 4 CHANGE ” Practice Location

Language	Start Address	Practice Location

These directions are for planning purposes only. You may find that construction projects, traffic, or other events may cause road conditions to differ from the map results.

Copyright © 2007-2026 (Powered by Swiss Vault Engine), all rights reserved. HIPAA liability, trademark, document use and software licensing rules apply. All registered trademarks, used in the content, are the property of their owners. Your interactions with this site are in accordance with our Terms of Use and Privacy Policy.