Provider Demographics
NPI:1518140599
Name:JACKSON PUBLIC SCHOOLS MCWILLIE CLINIC
Entity Type:Organization
Organization Name:JACKSON PUBLIC SCHOOLS MCWILLIE CLINIC
Other - Org Name:MCWILLIE ELEMENTARY SCHOOL CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:LEAD NURSE
Authorized Official - Prefix:MRS
Authorized Official - First Name:TAMMY
Authorized Official - Middle Name:D
Authorized Official - Last Name:CROCKER
Authorized Official - Suffix:
Authorized Official - Credentials:RN
Authorized Official - Phone:601-209-4456
Mailing Address - Street 1:618 S PRESIDENT ST
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:MS
Mailing Address - Zip Code:39201-5601
Mailing Address - Country:US
Mailing Address - Phone:601-960-8705
Mailing Address - Fax:
Practice Address - Street 1:4851 MCWILLIE CIR
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:MS
Practice Address - Zip Code:39206-5025
Practice Address - Country:US
Practice Address - Phone:601-209-4456
Practice Address - Fax:601-960-8704
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-12-12
Last Update Date:2007-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS02074355Medicaid