Provider Demographics
NPI:1588846281
Name:BEHAVIORAL MEDICINE CLINIC,PA
Entity Type:Organization
Organization Name:BEHAVIORAL MEDICINE CLINIC,PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:TERRY
Authorized Official - Middle Name:
Authorized Official - Last Name:JORDAN
Authorized Official - Suffix:
Authorized Official - Credentials:MM
Authorized Official - Phone:601-482-2400
Mailing Address - Street 1:5000 HWY 39 N
Mailing Address - Street 2:
Mailing Address - City:MERIDIAN
Mailing Address - State:MS
Mailing Address - Zip Code:39301-1021
Mailing Address - Country:US
Mailing Address - Phone:601-482-2400
Mailing Address - Fax:
Practice Address - Street 1:5000 HWY 39 N
Practice Address - Street 2:
Practice Address - City:MERIDIAN
Practice Address - State:MS
Practice Address - Zip Code:39301-1021
Practice Address - Country:US
Practice Address - Phone:601-482-2400
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-12-04
Last Update Date:2010-06-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS14095103TP0016X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TP0016XBehavioral Health & Social Service ProvidersPsychologistPrescribing (Medical)Group - Multi-Specialty