Provider Demographics
NPI:1134770415
Name:PAJARILLAGA, JOHN JOSEPH FERNANDEZ (P-LPC, CCSS, CADC)
Entity type:Individual
Prefix:
First Name:JOHN JOSEPH
Middle Name:FERNANDEZ
Last Name:PAJARILLAGA
Suffix:
Gender:M
Credentials:P-LPC, CCSS, CADC
Other - Prefix:
Other - First Name:JOHN
Other - Middle Name:JOSEPH
Other - Last Name:PAJARILLAGA
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:P-LPC, NCC, CADC
Mailing Address - Street 1:4325 MEADOWRIDGE DR
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:MS
Mailing Address - Zip Code:39206-5912
Mailing Address - Country:US
Mailing Address - Phone:216-406-6741
Mailing Address - Fax:
Practice Address - Street 1:141 TOWNSHIP AVE STE 303
Practice Address - Street 2:
Practice Address - City:RIDGELAND
Practice Address - State:MS
Practice Address - Zip Code:39157-8699
Practice Address - Country:US
Practice Address - Phone:601-790-0083
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-09-26
Last Update Date:2024-05-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS2876101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS02551264Medicaid