Organization
FONDREN MEDICAL CLINIC
Active
Organization subpart
No
Provider details
NPI number
Authorized official
DR. THERESA LEIJUAN LANE-FISHER P.H,D,PA (PHYSICIAN/OWNER)
(769) 257-5336
Entity
Organization
Contact information
Practice address
4436 N STATE ST, SUITE A-1, JACKSON, MS 39206-5334
(769) 257-5339
Mailing address
4436 N STATE ST, SUITE A-1, JACKSON, MS 39206-5334
(769) 257-5339
Taxonomy
Speciality
Code
Description
License number
State
261QP2300X
Primary Care Clinic/Center
Primary
—
—
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
00125523
—
MS
Enumeration date
06/22/2012
Last updated
06/22/2012
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