Provider Demographics
NPI:1225433436
Name:EVERYCARE EXPRESS CLINIC
Entity Type:Organization
Organization Name:EVERYCARE EXPRESS CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:NURSE PRACTITIONER
Authorized Official - Prefix:
Authorized Official - First Name:STEPHANIE
Authorized Official - Middle Name:
Authorized Official - Last Name:JACKSON
Authorized Official - Suffix:
Authorized Official - Credentials:FNP-BC
Authorized Official - Phone:601-859-0140
Mailing Address - Street 1:PO BOX 417
Mailing Address - Street 2:
Mailing Address - City:MADISON
Mailing Address - State:MS
Mailing Address - Zip Code:39130-0417
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:162 FEATHER LN
Practice Address - Street 2:SUITE E
Practice Address - City:CANTON
Practice Address - State:MS
Practice Address - Zip Code:39046-8510
Practice Address - Country:US
Practice Address - Phone:601-859-0140
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-10-30
Last Update Date:2014-12-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSR862558261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00780035Medicaid