Basic Information
| Provider Information | |||||||||
| NPI: | 1629694831 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | ADCOCK | ||||||||
| FirstName: | JESSICA | ||||||||
| MiddleName: | LEE | ||||||||
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| Mailing Information | |||||||||
| Address1: | 32 MILLBRANCH RD STE 40 | ||||||||
| Address2: | |||||||||
| City: | HATTIESBURG | ||||||||
| State: | MS | ||||||||
| PostalCode: | 394021673 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6012555264 | ||||||||
| FaxNumber: | 8666250559 | ||||||||
| Practice Location | |||||||||
| Address1: | 32 MILLBRANCH RD STE 40 | ||||||||
| Address2: | |||||||||
| City: | HATTIESBURG | ||||||||
| State: | MS | ||||||||
| PostalCode: | 394021673 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6012555264 | ||||||||
| FaxNumber: | 8666250559 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/23/2020 | ||||||||
| LastUpdateDate: | 12/13/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 12/13/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 106S00000X | N | 103K00000X | 1-21-48237 | FL | Y | Behavioral Health & Social Service Providers | Behavioral Analyst |
No ID Information.