# LEGACY 4 CHANGE

> Is this information incorrect? This page shows public data from NPPES. Update your record in NPPES and this page will update automatically within 7 days. [Update your NPPES record](https://nppes.cms.hhs.gov)

- **Entity:** Organization
- **Status:** Active
- **Organization subpart:** No

## Provider details

- **NPI number:** 1912664509
- **Authorized official:** CHASITY DAVIS (PRESIDENT)
- **Authorized official phone:** (769) 203-8141

## Contact information

- **Practice address:** 2891 TERRY RD, JACKSON, MS 39212-3051
- **Practice address phone:** (769) 203-8141
- **Mailing address:** PO BOX 821878, VICKSBURG, MS 39182-1878
- **Mailing address phone:** (769) 203-8141

## Taxonomy

| Code | Description | License number | State | Primary |
| --- | --- | --- | --- | --- |
| 1041C0700X | Clinical Social Worker | — | NULL | Yes |
| 1041C0700X | Clinical Social Worker | — | — | Yes |

## Other

- **Enumeration date:** 11/18/2021
- **Last updated:** 01/20/2022