Basic Information
Provider Information | |||||||||
NPI: | 1205021946 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | CENTRAL MISSISSIPPI CIVIC IMPROVEMENT ASSOCIATION, INC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | HOMELESS CLINIC | ||||||||
OtherOrganizationType: | 5 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 3502 W NORTHSIDE DR | ||||||||
Address2: |   | ||||||||
City: | JACKSON | ||||||||
State: | MS | ||||||||
PostalCode: | 392134454 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6013625321 | ||||||||
FaxNumber: | 6013642600 | ||||||||
Practice Location | |||||||||
Address1: | 327 S GALLATIN ST | ||||||||
Address2: |   | ||||||||
City: | JACKSON | ||||||||
State: | MS | ||||||||
PostalCode: | 392033514 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6013625321 | ||||||||
FaxNumber: | 6013642600 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 09/06/2007 | ||||||||
LastUpdateDate: | 10/29/2010 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | CHAPMAN | ||||||||
AuthorizedOfficialFirstName: | JASMIN | ||||||||
AuthorizedOfficialMiddleName: | R | ||||||||
AuthorizedOfficialTitleorPosition: | CEO | ||||||||
AuthorizedOfficialTelephone: | 6013625321 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: | DR. | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: | DDS | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QF0400X |   |   | Y |   | Ambulatory Health Care Facilities | Clinic/Center | Federally Qualified Health Center (FQHC) |
ID Information
ID | Type | State | Issuer | Description | 09014683 | 05 | MS |   | MEDICAID |