1528302452 NPI number — COUNSELING AND MENTORING PROGRAM 2.0

Table of content: (NPI 1528302452)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1528302452 NPI number — COUNSELING AND MENTORING PROGRAM 2.0

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
COUNSELING AND MENTORING PROGRAM 2.0
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:
C.A.M.P. 2.0
Provider Other Organization Name Type Code:
3
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:
1528302452
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
11/15/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2460 TERRY ROAD SUITE 1900
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
JACKSON
Provider Business Mailing Address State Name:
MS
Provider Business Mailing Address Postal Code:
39204
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
601-372-3085
Provider Business Mailing Address Fax Number:
601-372-3086

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2460 TERRY RD STE 1900
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
JACKSON
Provider Business Practice Location Address State Name:
MS
Provider Business Practice Location Address Postal Code:
39204-5767
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
601-372-3085
Provider Business Practice Location Address Fax Number:
601-372-3086
Provider Enumeration Date:
11/15/2012

Additional Information

Authorized Official

Authorized Official Last Name:
LYNCH
Authorized Official First Name:
JAZMIN
Authorized Official Middle Name:
SHANTE
Authorized Official Title or Position:
ADMINISTRATOR
Authorized Official Telephone Number:
601-371-3085

Provider Taxonomy Codes

  • Taxonomy code: 104100000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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