Provider Demographics
NPI:1235513714
Name:HANDS OF GODDESS
Entity type:Organization
Organization Name:HANDS OF GODDESS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/CEO
Authorized Official - Prefix:
Authorized Official - First Name:JEKORY
Authorized Official - Middle Name:JUANTE
Authorized Official - Last Name:JEFFERSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:601-316-0156
Mailing Address - Street 1:208 E GEORGETOWN ST
Mailing Address - Street 2:
Mailing Address - City:CRYSTAL SPRINGS
Mailing Address - State:MS
Mailing Address - Zip Code:39059-2517
Mailing Address - Country:US
Mailing Address - Phone:601-308-5150
Mailing Address - Fax:601-308-5157
Practice Address - Street 1:208 E GEORGETOWN ST
Practice Address - Street 2:
Practice Address - City:CRYSTAL SPRINGS
Practice Address - State:MS
Practice Address - Zip Code:39059-2517
Practice Address - Country:US
Practice Address - Phone:601-308-5150
Practice Address - Fax:601-308-5157
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-07-15
Last Update Date:2015-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSR603643305S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes305S00000XManaged Care OrganizationsPoint of Service