Provider Demographics
NPI:1679135982
Name:PRIMARY AND BEHAVIORAL HEALTHCARE SERVICES, PA
Entity Type:Organization
Organization Name:PRIMARY AND BEHAVIORAL HEALTHCARE SERVICES, PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MS
Authorized Official - First Name:SHAMECA
Authorized Official - Middle Name:LEONORA
Authorized Official - Last Name:HUDSON
Authorized Official - Suffix:
Authorized Official - Credentials:FNP, DNP-BC, PMHNP-B
Authorized Official - Phone:769-572-4009
Mailing Address - Street 1:717 E FORTIFICATION ST
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:MS
Mailing Address - Zip Code:39202-2402
Mailing Address - Country:US
Mailing Address - Phone:769-572-4009
Mailing Address - Fax:769-572-4021
Practice Address - Street 1:717 E FORTIFICATION ST
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:MS
Practice Address - Zip Code:39202-2402
Practice Address - Country:US
Practice Address - Phone:769-572-4009
Practice Address - Fax:769-572-4021
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-07-08
Last Update Date:2019-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty