Provider Demographics
NPI:1801316807
Name:WYATT & JACKSON CENTER FOR CHANGE, LLC
Entity type:Organization
Organization Name:WYATT & JACKSON CENTER FOR CHANGE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:MOLLIE
Authorized Official - Middle Name:L
Authorized Official - Last Name:WYATT
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:601-981-8846
Mailing Address - Street 1:2637 RIDGEWOOD RD STE 100
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:MS
Mailing Address - Zip Code:39216-4922
Mailing Address - Country:US
Mailing Address - Phone:601-981-8846
Mailing Address - Fax:601-981-8873
Practice Address - Street 1:2637 RIDGEWOOD ROAD SUITE 100
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:MS
Practice Address - Zip Code:39216
Practice Address - Country:US
Practice Address - Phone:601-981-8846
Practice Address - Fax:601-981-8873
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-06-21
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Single Specialty