Provider Demographics
NPI:1598943631
Name:MS STATE HOSPITAL CRISIS INTERVENTION CENTER-BROOKHAVEN
Entity type:Organization
Organization Name:MS STATE HOSPITAL CRISIS INTERVENTION CENTER-BROOKHAVEN
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PROVIDER ENROLLMENT
Authorized Official - Prefix:MS
Authorized Official - First Name:JACQUELINE
Authorized Official - Middle Name:
Authorized Official - Last Name:KING
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:601-351-8000
Mailing Address - Street 1:725 BROOKMAN DR EXT
Mailing Address - Street 2:
Mailing Address - City:BROOKHAVEN
Mailing Address - State:MS
Mailing Address - Zip Code:39601-2311
Mailing Address - Country:US
Mailing Address - Phone:601-351-8000
Mailing Address - Fax:601-351-8586
Practice Address - Street 1:725 BROOKMAN DR EXT
Practice Address - Street 2:
Practice Address - City:BROOKHAVEN
Practice Address - State:MS
Practice Address - Zip Code:39601-2311
Practice Address - Country:US
Practice Address - Phone:601-351-8000
Practice Address - Fax:601-351-8586
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-01-31
Last Update Date:2008-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS31-345283Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes283Q00000XHospitalsPsychiatric Hospital