Provider Demographics
NPI:1790717080
Name:CENTRAL MISSISSIPPI CIVIC IMPROVEMENT ASSOCIATION
Entity Type:Organization
Organization Name:CENTRAL MISSISSIPPI CIVIC IMPROVEMENT ASSOCIATION
Other - Org Name:JACKSON HINDS COMPREHENSIVE HEALTH CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:JASMIN
Authorized Official - Middle Name:
Authorized Official - Last Name:CHAPMAN
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:601-362-5321
Mailing Address - Street 1:3502 W NORTHSIDE DR
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:MS
Mailing Address - Zip Code:39213-4454
Mailing Address - Country:US
Mailing Address - Phone:601-362-5321
Mailing Address - Fax:
Practice Address - Street 1:3502 W NORTHSIDE DR
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:MS
Practice Address - Zip Code:39213-4454
Practice Address - Country:US
Practice Address - Phone:601-362-5321
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:CENTRAL MISSISSIPPI CIVIC IMPROVEMENT ASSOCIATION
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-07-07
Last Update Date:2011-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental
No261QF0400XAmbulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS09013452Medicaid