Provider Demographics
NPI:1528610326
Name:MANGUM-JOHNSON, BENETRA (PHD, LCSW)
Entity type:Individual
Prefix:DR
First Name:BENETRA
Middle Name:
Last Name:MANGUM-JOHNSON
Suffix:
Gender:F
Credentials:PHD, LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2500 NORTH STATE STREET
Mailing Address - Street 2:CBO - SUITE 4200
Mailing Address - City:JACKSON
Mailing Address - State:MS
Mailing Address - Zip Code:39216-4500
Mailing Address - Country:US
Mailing Address - Phone:601-496-9794
Mailing Address - Fax:601-815-0434
Practice Address - Street 1:2500 N. STATE ST.
Practice Address - Street 2:DEPT. OF PSYCHIATRY AND HUMAN BEHAVIOR (H808)
Practice Address - City:JACKSON
Practice Address - State:MS
Practice Address - Zip Code:39216
Practice Address - Country:US
Practice Address - Phone:601-815-6337
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-07-11
Last Update Date:2019-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSC71801041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical