Provider Demographics
NPI:1194964049
Name:BEACON BEHAVIORAL HEALTH-JACKSON
Entity type:Organization
Organization Name:BEACON BEHAVIORAL HEALTH-JACKSON
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:PHILLIP
Authorized Official - Middle Name:
Authorized Official - Last Name:WENDELL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:225-810-4040
Mailing Address - Street 1:9938 AIRLINE HIGHWAY
Mailing Address - Street 2:SUITE 200
Mailing Address - City:BATON ROUGE
Mailing Address - State:LA
Mailing Address - Zip Code:70816
Mailing Address - Country:US
Mailing Address - Phone:225-810-4040
Mailing Address - Fax:225-810-4050
Practice Address - Street 1:5360 I 55 N
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:MS
Practice Address - Zip Code:39211-4026
Practice Address - Country:US
Practice Address - Phone:601-373-4507
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-02-17
Last Update Date:2009-02-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS261QM0801X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)