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Organization
LEGACY 4 CHANGE
Active
Organization
LEGACY 4 CHANGE
Active
Organization subpart
No
Provider details
NPI number
Authorized official
CHASITY DAVIS (PRESIDENT)
(769) 203-8141
Entity
Organization
Contact information
Practice address
2891 TERRY RD, JACKSON, MS 39212-3051
(769) 203-8141
Mailing address
PO BOX 821878, VICKSBURG, MS 39182-1878
(769) 203-8141
Taxonomy
Speciality
Code
Description
License number
State
1041C0700X
Clinical Social Worker
Primary
—
NULL
1041C0700X
Clinical Social Worker
Primary
—
—
Other
Enumeration date
11/18/2021
Last updated
01/20/2022
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