Organization
EXTENSIONS OF LIVING, LLC
Active
Organization subpart
No
Provider details
NPI number
Authorized official
MISS VICKI RENEE JACKSON (DIRECTOR)
(601) 582-4695
Entity
Organization
Contact information
Practice address
301 HUMBLE AVE, SUITE 174, HATTIESBURG, MS 39401-6365
(601) 582-4695
(601) 582-8178
Mailing address
301 HUMBLE AVE, SUITE 174, HATTIESBURG, MS 39401-6365
(601) 582-4695
(601) 582-8178
Taxonomy
Speciality
Code
Description
License number
State
376J00000X
Homemaker
Primary
07589517
MS
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
07589517
—
MS
05
—
07628574
—
MS
Enumeration date
01/11/2012
Last updated
01/11/2012
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