| Full Name | |
|---|---|
| Speciality | Community/behavioral Health |
| Location | 3828 I 55 N, Jackson, Mississippi |
| Authorized Official Name and Position | Larry Jensen (VICE PRESIDENT, OPERATIONS) |
| Authorized Official Contact | 3127954683 |
| Accepts Medicare Insurance | This clinic does not participate in Medicare Program. |
| Mailing Address | Practice Location Address |
|---|---|
1 N State St Ste 800 Chicago IL 60602-3312 Ph: (312) 795-4683 | 3828 I 55 N Jackson MS 39211-6324 Ph: (601) 982-7311 |
| NPI Number | 1962999326 |
|---|---|
| Provider Enumeration Date | 04/20/2018 |
| Last Update Date | 04/20/2018 |
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 1962999326 | NPI | - | NPPES |
| Taxonomy | Type | License (State) | Status |
|---|---|---|---|
| 251S00000X | Community/behavioral Health | (* (Not Available)) | Primary |
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