Provider Demographics
NPI:1386991230
Name:COMPASSIONATE HEARTS
Entity type:Organization
Organization Name:COMPASSIONATE HEARTS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CLINICAL SERVICE DIRECTOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:KIRA
Authorized Official - Middle Name:
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:769-233-8585
Mailing Address - Street 1:1828 RAYMOND RD
Mailing Address - Street 2:SUITE A
Mailing Address - City:JACKSON
Mailing Address - State:MS
Mailing Address - Zip Code:39204-4126
Mailing Address - Country:US
Mailing Address - Phone:769-233-8585
Mailing Address - Fax:877-907-6577
Practice Address - Street 1:1828 RAYMOND RD
Practice Address - Street 2:SUITE A
Practice Address - City:JACKSON
Practice Address - State:MS
Practice Address - Zip Code:39204-4126
Practice Address - Country:US
Practice Address - Phone:769-233-8585
Practice Address - Fax:877-907-6577
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-08-10
Last Update Date:2015-06-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSC66961041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS06202806Medicaid