Provider Demographics
NPI:1780127845
Name:JOURNEYPURE MISSISSIPPI MEDICAL GROUP LLC
Entity type:Organization
Organization Name:JOURNEYPURE MISSISSIPPI MEDICAL GROUP LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:HUMAN RESOURCES
Authorized Official - Prefix:
Authorized Official - First Name:KIM
Authorized Official - Middle Name:
Authorized Official - Last Name:COOPER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:662-536-6542
Mailing Address - Street 1:8829 CENTRE ST STE 200
Mailing Address - Street 2:
Mailing Address - City:SOUTHAVEN
Mailing Address - State:MS
Mailing Address - Zip Code:38671-2610
Mailing Address - Country:US
Mailing Address - Phone:662-536-6542
Mailing Address - Fax:662-314-9689
Practice Address - Street 1:8829 CENTRE ST
Practice Address - Street 2:
Practice Address - City:SOUTHAVEN
Practice Address - State:MS
Practice Address - Zip Code:38671-2610
Practice Address - Country:US
Practice Address - Phone:662-536-6542
Practice Address - Fax:662-314-9689
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-11-22
Last Update Date:2020-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TA0400XBehavioral Health & Social Service ProvidersPsychologistAddiction (Substance Use Disorder)Group - Multi-Specialty