Provider Demographics
NPI:1912645623
Name:JACKSON CENTER
Entity Type:Organization
Organization Name:JACKSON CENTER
Other - Org Name:THE JACKSON CENTER FOR MENTAL WELLNESS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MEMBER
Authorized Official - Prefix:
Authorized Official - First Name:BEN
Authorized Official - Middle Name:
Authorized Official - Last Name:HARRELL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:901-647-8291
Mailing Address - Street 1:470 NORTH ST
Mailing Address - Street 2:
Mailing Address - City:HERNANDO
Mailing Address - State:MS
Mailing Address - Zip Code:38632-1732
Mailing Address - Country:US
Mailing Address - Phone:901-647-8291
Mailing Address - Fax:
Practice Address - Street 1:198 NARROWS DR STE 105
Practice Address - Street 2:
Practice Address - City:BIRMINGHAM
Practice Address - State:AL
Practice Address - Zip Code:35242-8663
Practice Address - Country:US
Practice Address - Phone:901-647-8291
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-05-23
Last Update Date:2022-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental HealthGroup - Single Specialty