Provider Demographics
NPI:1740310549
Name:JULIA STREET CLINIC, INC.
Entity type:Organization
Organization Name:JULIA STREET CLINIC, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:VERNITA
Authorized Official - Middle Name:
Authorized Official - Last Name:JAMES
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:662-962-7923
Mailing Address - Street 1:PO BOX 553
Mailing Address - Street 2:
Mailing Address - City:ISOLA
Mailing Address - State:MS
Mailing Address - Zip Code:38754-0553
Mailing Address - Country:US
Mailing Address - Phone:662-962-7923
Mailing Address - Fax:662-962-2576
Practice Address - Street 1:102 JULIA STREET
Practice Address - Street 2:
Practice Address - City:ISOLA
Practice Address - State:MS
Practice Address - Zip Code:38754
Practice Address - Country:US
Practice Address - Phone:662-962-7923
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-07
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QC1500XAmbulatory Health Care FacilitiesClinic/CenterCommunity Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS01285834Medicaid