Provider Demographics
NPI:1558566398
Name:HERITAGE HOME HEALTH AGENCY
Entity Type:Organization
Organization Name:HERITAGE HOME HEALTH AGENCY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:MS
Authorized Official - First Name:SHIRLEY
Authorized Official - Middle Name:Q
Authorized Official - Last Name:ANDERSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:601-981-5973
Mailing Address - Street 1:931 HIGHWAY 80 W
Mailing Address - Street 2:SUITE 216
Mailing Address - City:JACKSON
Mailing Address - State:MS
Mailing Address - Zip Code:39204-3912
Mailing Address - Country:US
Mailing Address - Phone:601-981-5973
Mailing Address - Fax:601-713-2437
Practice Address - Street 1:931 HIGHWAY 80 W
Practice Address - Street 2:SUITE 216
Practice Address - City:JACKSON
Practice Address - State:MS
Practice Address - Zip Code:39204-3912
Practice Address - Country:US
Practice Address - Phone:601-981-5973
Practice Address - Fax:601-713-2437
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-06-20
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS251E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00770538Medicaid
MS00425253Medicaid
MS00425253Medicaid