Basic Information
| Provider Information | |||||||||
| NPI: | 1750799383 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | CENTRAL MISSISSIPPI CIVIC IMPROVEMENT ASSOCIATION, INC. | ||||||||
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| OtherOrganizationName: | JACKSON-HINDS COMPREHENSIVE HEALTH CENTER - TERRY HIGH SCHOOL-BASED CL | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3502 W NORTHSIDE DR | ||||||||
| Address2: | |||||||||
| City: | JACKSON | ||||||||
| State: | MS | ||||||||
| PostalCode: | 392134454 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6013625321 | ||||||||
| FaxNumber: | 6013645159 | ||||||||
| Practice Location | |||||||||
| Address1: | 235 W BEASLEY ST | ||||||||
| Address2: | |||||||||
| City: | TERRY | ||||||||
| State: | MS | ||||||||
| PostalCode: | 391708154 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6013625321 | ||||||||
| FaxNumber: | 6013645159 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/28/2014 | ||||||||
| LastUpdateDate: | 07/28/2014 | ||||||||
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| AuthorizedOfficialLastName: | CHAPMAN | ||||||||
| AuthorizedOfficialFirstName: | JASMIN | ||||||||
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| AuthorizedOfficialTitleorPosition: | CHIEF EXECUTIVE OFFICER | ||||||||
| AuthorizedOfficialTelephone: | 6013625321 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | DDS | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QF0400X | Y | Ambulatory Health Care Facilities | Clinic/Center | Federally Qualified Health Center (FQHC) |
No ID Information.