Provider Demographics
NPI:1265814420
Name:TIFFANY DANIELS
Entity Type:Organization
Organization Name:TIFFANY DANIELS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:
Authorized Official - Last Name:MARION
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:601-956-4816
Mailing Address - Street 1:PO BOX 13509
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:MS
Mailing Address - Zip Code:39236-3509
Mailing Address - Country:US
Mailing Address - Phone:601-956-4816
Mailing Address - Fax:601-956-4817
Practice Address - Street 1:5760 I 55 N STE 450
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:MS
Practice Address - Zip Code:39211-2673
Practice Address - Country:US
Practice Address - Phone:601-956-4816
Practice Address - Fax:601-956-4817
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-06-24
Last Update Date:2015-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSM7826261QM0801X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)