Provider Demographics
NPI:1083079545
Name:GARRETT, GENEVIEVE CELESTE (LCSW, MPH, CHES)
Entity Type:Individual
Prefix:
First Name:GENEVIEVE
Middle Name:CELESTE
Last Name:GARRETT
Suffix:
Gender:F
Credentials:LCSW, MPH, CHES
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2500 N STATE ST
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:MS
Mailing Address - Zip Code:39216-4500
Mailing Address - Country:US
Mailing Address - Phone:601-984-2955
Mailing Address - Fax:
Practice Address - Street 1:5903 RIDGEWOOD RD
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:MS
Practice Address - Zip Code:39211-3700
Practice Address - Country:US
Practice Address - Phone:601-984-2955
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-12-28
Last Update Date:2016-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSC70881041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS03070721Medicaid
MS466938YJ5DMedicare PIN