Provider Demographics
NPI:1740980655
Name:HAGG, JUSTICE IVY
Entity type:Individual
Prefix:
First Name:JUSTICE
Middle Name:IVY
Last Name:HAGG
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 1:1070 WILSON RDG
Mailing Address - Street 2:
Mailing Address - City:LAKE CORMORANT
Mailing Address - State:MS
Mailing Address - Zip Code:38641-9486
Mailing Address - Country:US
Mailing Address - Phone:901-463-8873
Mailing Address - Fax:
Practice Address - Street 1:1070 WILSON RDG
Practice Address - Street 2:
Practice Address - City:LAKE CORMORANT
Practice Address - State:MS
Practice Address - Zip Code:38641-9486
Practice Address - Country:US
Practice Address - Phone:901-463-8873
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-03-08
Last Update Date:2023-03-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician