Provider Demographics
NPI:1528302452
Name:COUNSELING AND MENTORING PROGRAM 2.0
Entity type:Organization
Organization Name:COUNSELING AND MENTORING PROGRAM 2.0
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MS
Authorized Official - First Name:JAZMIN
Authorized Official - Middle Name:SHANTE
Authorized Official - Last Name:LYNCH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:601-371-3085
Mailing Address - Street 1:2460 TERRY ROAD SUITE 1900
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:MS
Mailing Address - Zip Code:39204
Mailing Address - Country:US
Mailing Address - Phone:601-372-3085
Mailing Address - Fax:601-372-3086
Practice Address - Street 1:2460 TERRY RD STE 1900
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:MS
Practice Address - Zip Code:39204-5767
Practice Address - Country:US
Practice Address - Phone:601-372-3085
Practice Address - Fax:601-372-3086
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-11-15
Last Update Date:2012-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes104100000XBehavioral Health & Social Service ProvidersSocial WorkerGroup - Single Specialty