Provider Demographics
NPI:1073679817
Name:COPAC ADDICTION SERVICES
Entity Type:Organization
Organization Name:COPAC ADDICTION SERVICES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:FAMILY NURSE PRACTITIONER
Authorized Official - Prefix:
Authorized Official - First Name:WANDA
Authorized Official - Middle Name:NEWTON
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:CFNP
Authorized Official - Phone:601-829-2500
Mailing Address - Street 1:5857 KRISTEN DR
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:MS
Mailing Address - Zip Code:39211-2831
Mailing Address - Country:US
Mailing Address - Phone:601-956-0303
Mailing Address - Fax:
Practice Address - Street 1:3949 HIGHWAY 43 N
Practice Address - Street 2:
Practice Address - City:BRANDON
Practice Address - State:MS
Practice Address - Zip Code:39047-7240
Practice Address - Country:US
Practice Address - Phone:601-829-2500
Practice Address - Fax:601-829-4278
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-28
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSR586986324500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes324500000XResidential Treatment FacilitiesSubstance Abuse Rehabilitation Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
MSMJ1222063OtherDEA NUMBER
MS560600Medicare UPIN