Provider Demographics
NPI:1710545488
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:CHIEF EXECUTIVE OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:SHAMECA
Authorized Official - Middle Name:L
Authorized Official - Last Name:HUDSON
Authorized Official - Suffix:
Authorized Official - Credentials:DNP, FNP-BC
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 1:2252 TOWER DR STE 108
Practice Address - Street 2:
Practice Address - City:MONROE
Practice Address - State:LA
Practice Address - Zip Code:71201-5765
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:2019-05-29
Last Update Date:2021-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental HealthGroup - Multi-Specialty
No261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00000000Medicaid