Provider Demographics
NPI:1659527414
Name:JACKSON PUBLIC SCHOOLS CLAUSELL CLINIC
Entity Type:Organization
Organization Name:JACKSON PUBLIC SCHOOLS CLAUSELL CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:LEAD NURSE
Authorized Official - Prefix:MRS
Authorized Official - First Name:TAMMY
Authorized Official - Middle Name:DARLENE
Authorized Official - Last Name:CROCKER
Authorized Official - Suffix:
Authorized Official - Credentials:RN
Authorized Official - Phone:601-209-4456
Mailing Address - Street 1:3330 HARLEY ST
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:MS
Mailing Address - Zip Code:39209-7239
Mailing Address - Country:US
Mailing Address - Phone:601-960-8705
Mailing Address - Fax:
Practice Address - Street 1:618 S PRESIDENT ST
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:MS
Practice Address - Zip Code:39201-5601
Practice Address - Country:US
Practice Address - Phone:601-960-8705
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-08-13
Last Update Date:2008-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSR557579163WS0200X
261QS1000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QS1000XAmbulatory Health Care FacilitiesClinic/CenterStudent Health
No163WS0200XNursing Service ProvidersRegistered NurseSchoolGroup - Single Specialty