Provider Demographics
NPI:1770246290
Name:WALTERS, REBECCA JILL (LCSW)
Entity Type:Individual
Prefix:
First Name:REBECCA
Middle Name:JILL
Last Name:WALTERS
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:REBECCA
Other - Middle Name:JILL
Other - Last Name:MCVAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LCSW
Mailing Address - Street 1:7731 OLD CANTON RD STE B
Mailing Address - Street 2:
Mailing Address - City:MADISON
Mailing Address - State:MS
Mailing Address - Zip Code:39110-6115
Mailing Address - Country:US
Mailing Address - Phone:601-499-0935
Mailing Address - Fax:601-499-0936
Practice Address - Street 1:401 BAPTIST DR STE 301
Practice Address - Street 2:
Practice Address - City:MADISON
Practice Address - State:MS
Practice Address - Zip Code:39110-2012
Practice Address - Country:US
Practice Address - Phone:601-499-0935
Practice Address - Fax:601-499-0936
Is Sole Proprietor?:No
Enumeration Date:2021-10-21
Last Update Date:2024-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
104100000X
MSM91491041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No104100000XBehavioral Health & Social Service ProvidersSocial Worker