1982795290 NPI number — MISS JESSICA IRENE STOCKMAN LPC

Table of content: MISS JESSICA IRENE STOCKMAN LPC (NPI 1982795290)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1982795290 NPI number — MISS JESSICA IRENE STOCKMAN LPC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
STOCKMAN
Provider First Name:
JESSICA
Provider Middle Name:
IRENE
Provider Name Prefix Text:
MISS
Provider Name Suffix Text:
Provider Credential Text:
LPC
Provider Gender Code:
F

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:
1982795290
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
01/27/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
7685 VERANDA BLVD
Provider Second Line Business Mailing Address:
#2
Provider Business Mailing Address City Name:
SOUTHAVEN
Provider Business Mailing Address State Name:
MS
Provider Business Mailing Address Postal Code:
38671-3964
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
801-473-1051
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
7075 GOLDEN OAKS LOOP W
Provider Second Line Business Practice Location Address:
STE. 3
Provider Business Practice Location Address City Name:
SOUTHAVEN
Provider Business Practice Location Address State Name:
MS
Provider Business Practice Location Address Postal Code:
38671-9010
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
662-349-3980
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
09/28/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 101YP2500X , with the licence number:  1185 , 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)





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