Provider Demographics
NPI:1649879461
Name:GREEN, JOYCELYN
Entity type:Individual
Prefix:
First Name:JOYCELYN
Middle Name:
Last Name:GREEN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1110 CLAY ST
Mailing Address - Street 2:
Mailing Address - City:VICKSBURG
Mailing Address - State:MS
Mailing Address - Zip Code:39183-2912
Mailing Address - Country:US
Mailing Address - Phone:601-738-5820
Mailing Address - Fax:601-738-5083
Practice Address - Street 1:1110 CLAY ST
Practice Address - Street 2:
Practice Address - City:VICKSBURG
Practice Address - State:MS
Practice Address - Zip Code:39183-2912
Practice Address - Country:US
Practice Address - Phone:601-738-5820
Practice Address - Fax:601-738-5083
Is Sole Proprietor?:No
Enumeration Date:2020-10-22
Last Update Date:2022-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YM0800X
MSC84011041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health