Provider Demographics
NPI:1780405738
Name:MENDED HEARTS COUNSELING SERVICES, LLC
Entity type:Organization
Organization Name:MENDED HEARTS COUNSELING SERVICES, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:MIRIAM
Authorized Official - Middle Name:
Authorized Official - Last Name:JACKSON-HAMILTON
Authorized Official - Suffix:
Authorized Official - Credentials:DPC
Authorized Official - Phone:662-347-9999
Mailing Address - Street 1:159 PARKWAY AVE
Mailing Address - Street 2:
Mailing Address - City:ROLLING FORK
Mailing Address - State:MS
Mailing Address - Zip Code:39159-5112
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:159 PARKWAY AVE
Practice Address - Street 2:
Practice Address - City:ROLLING FORK
Practice Address - State:MS
Practice Address - Zip Code:39159-5112
Practice Address - Country:US
Practice Address - Phone:662-347-9999
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-10-22
Last Update Date:2024-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Multi-Specialty