Provider Demographics
NPI:1366655896
Name:PUCKETT, TAMARA L (LPC)
Entity Type:Individual
Prefix:MS
First Name:TAMARA
Middle Name:L
Last Name:PUCKETT
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4500 I 55 N STE 293S
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:MS
Mailing Address - Zip Code:39211-5966
Mailing Address - Country:US
Mailing Address - Phone:601-613-6088
Mailing Address - Fax:601-362-4089
Practice Address - Street 1:4500 I 55 N
Practice Address - Street 2:SUITE 293-S
Practice Address - City:JACKSON
Practice Address - State:MS
Practice Address - Zip Code:39211-5930
Practice Address - Country:US
Practice Address - Phone:601-982-5943
Practice Address - Fax:601-362-4089
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-08
Last Update Date:2008-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS0888101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS$$$$$$$$$OtherBCBSMS