Basic Information
| Provider Information | |||||||||
| NPI: | 1639354418 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | HAMMOND | ||||||||
| FirstName: | PHYLLIS | ||||||||
| MiddleName: | T | ||||||||
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| Credential: | MSSW, LCSW | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5440 EXECUTIVE PL STE B | ||||||||
| Address2: | |||||||||
| City: | JACKSON | ||||||||
| State: | MS | ||||||||
| PostalCode: | 392064145 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6012124856 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1171 HART ST | ||||||||
| Address2: | |||||||||
| City: | CANTON | ||||||||
| State: | MS | ||||||||
| PostalCode: | 390464805 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6018599888 | ||||||||
| FaxNumber: | 6018599004 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/30/2007 | ||||||||
| LastUpdateDate: | 04/22/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 04/22/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041C0700X | C1607 | MS | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical |
ID Information
| ID | Type | State | Issuer | Description | 000456093 | 01 | MS | OPTUM (UHC) | OTHER | 02632342 | 05 | MS | MEDICAID | 1639354418 | 01 | MS | CENPATICO | OTHER |