1033510391 NPI number — THE JOURNEY RESOURCE CENTER

Table of content: (NPI 1033510391)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1033510391 NPI number — THE JOURNEY RESOURCE CENTER

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
THE JOURNEY RESOURCE CENTER
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1033510391
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
09/05/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
30 COUNTY ROAD 7051
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BOONEVILLE
Provider Business Mailing Address State Name:
MS
Provider Business Mailing Address Postal Code:
38829-7517
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
662-760-0115
Provider Business Mailing Address Fax Number:
662-489-7298

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
114 E BOLTON ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
PONTOTOC
Provider Business Practice Location Address State Name:
MS
Provider Business Practice Location Address Postal Code:
38863-1506
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
660-760-0115
Provider Business Practice Location Address Fax Number:
662-489-7298
Provider Enumeration Date:
09/05/2014

Additional Information

Authorized Official

Authorized Official Last Name:
KELLY
Authorized Official First Name:
KIMBERLY
Authorized Official Middle Name:
ANN
Authorized Official Title or Position:
COUNSELOR
Authorized Official Telephone Number:
662-760-0115

Provider Taxonomy Codes

  • Taxonomy code: 101YP2500X , with the licence number:  1923 , registered in the state of MS ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 1923 . This is a "COUNSELOR" identifier , issued by the state of ( MS ) . This identifiers is of the category "OTHER".




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