Provider Demographics
NPI:1871077651
Name:BRUCE, TINA A
Entity type:Individual
Prefix:
First Name:TINA
Middle Name:A
Last Name:BRUCE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:860 E RIVER PL STE 100860
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:MS
Mailing Address - Zip Code:39202-3442
Mailing Address - Country:US
Mailing Address - Phone:769-251-5550
Mailing Address - Fax:
Practice Address - Street 1:522 W PARK AVE
Practice Address - Street 2:
Practice Address - City:GREENWOOD
Practice Address - State:MS
Practice Address - Zip Code:38930-2906
Practice Address - Country:US
Practice Address - Phone:662-374-5029
Practice Address - Fax:662-374-5032
Is Sole Proprietor?:No
Enumeration Date:2018-09-18
Last Update Date:2018-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker