Provider Demographics
NPI:1750688446
Name:MATHIS, LASHONDA TRENNELL (MSW)
Entity Type:Individual
Prefix:MRS
First Name:LASHONDA
Middle Name:TRENNELL
Last Name:MATHIS
Suffix:
Gender:F
Credentials:MSW
Other - Prefix:MS
Other - First Name:LASHONDA
Other - Middle Name:TRENNELL
Other - Last Name:NETTLES
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MSW
Mailing Address - Street 1:860 E RIVER PL STE 100
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:MS
Mailing Address - Zip Code:39202-3442
Mailing Address - Country:US
Mailing Address - Phone:228-712-8024
Mailing Address - Fax:228-712-8027
Practice Address - Street 1:3452 PASCAGOULA ST
Practice Address - Street 2:
Practice Address - City:PASCAGOULA
Practice Address - State:MS
Practice Address - Zip Code:39567-3203
Practice Address - Country:US
Practice Address - Phone:228-712-8024
Practice Address - Fax:228-712-8027
Is Sole Proprietor?:No
Enumeration Date:2011-02-16
Last Update Date:2021-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
No171M00000XOther Service ProvidersCase Manager/Care Coordinator
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00018214Medicaid