Provider Demographics
NPI:1235888413
Name:CHILDRENS SPECIALTY CLINIC OF LAUREL
Entity Type:Organization
Organization Name:CHILDRENS SPECIALTY CLINIC OF LAUREL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:JESSICA
Authorized Official - Middle Name:
Authorized Official - Last Name:MCKINNON
Authorized Official - Suffix:
Authorized Official - Credentials:PMHNP
Authorized Official - Phone:601-498-5009
Mailing Address - Street 1:2110A SANDY LN
Mailing Address - Street 2:
Mailing Address - City:LAUREL
Mailing Address - State:MS
Mailing Address - Zip Code:39443-9087
Mailing Address - Country:US
Mailing Address - Phone:601-498-5009
Mailing Address - Fax:
Practice Address - Street 1:2110A SANDY LN
Practice Address - Street 2:
Practice Address - City:LAUREL
Practice Address - State:MS
Practice Address - Zip Code:39443-9087
Practice Address - Country:US
Practice Address - Phone:601-498-5009
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-03-23
Last Update Date:2022-03-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental HealthGroup - Single Specialty