1336521970 NPI number — DEIDERE HOLLINS LPC-S

Table of content: DEIDERE HOLLINS LPC-S (NPI 1336521970)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1336521970 NPI number — DEIDERE HOLLINS LPC-S

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
HOLLINS
Provider First Name:
DEIDERE
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
LPC-S
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:
1336521970
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/11/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
109 MAGNOLIA WAY
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
PEARL
Provider Business Mailing Address State Name:
MS
Provider Business Mailing Address Postal Code:
39208-3366
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
601-573-9849
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3450 HIGHWAY 80 W
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:
39209-7201
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
601-321-2400
Provider Business Practice Location Address Fax Number:
601-985-5174
Provider Enumeration Date:
06/19/2015

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:  1628 , 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: 00018209 , issued by the state of ( MS ) . This identifiers is of the category "MEDICAID".




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