NPIMap

Organization Active NPI

Mall Services, LLC

  • Family Nurse Practitioner
  • Jackson, MS
National Provider Identifier
1063659340
Registry record updated Jan 8, 2009
On this page

Key facts

NPPES NPI Registry
Primary specialty
Family Nurse PractitionerTaxonomy code 363LF0000X
License
R656046 Issued in MS
Legal business name
MALL SERVICES, LLC
Doing business as
809 Convenient Care Clinic
Practice address
809 N State St
Jackson, MS 39202-2604
Phone
(601) 982-0673
Fax
(601) 982-0459
NPI assigned
Jan 8, 2009
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Jan 8, 2009

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name
Mrs. Christal Rogers, LPN
Title
Office Assistant
Phone
(601) 982-0673

Specialties & licenses 2

Specialty (taxonomy)CodeLicenseStatePrimary
Community Health WorkerGroup: 193400000X MULTIPLE SINGLE SPECIALTY GROUP 172V00000X P320574 MS
Family Nurse PractitionerGroup: 193400000X MULTIPLE SINGLE SPECIALTY GROUP 363LF0000X R656046 MS Primary

Addresses

Primary practice location

809 N State St
Jackson, MS 39202-2604

Mailing address

350 W Woodrow Wilson Ave
Suite 615
Jackson, MS 39213-7681
Phone (601) 982-0673

Other identifiers 2

IdentifierTypeStateIssuer
00115980MedicaidMS
08406271MedicaidMS

Other names 1

  • 809 Convenient Care Clinic Doing business as

National Provider Directory

National Provider Directory
Tax ID family
Mall Services LLC8 organizations share this tax ID, including this one

Other organizations with this tax ID 7

Organizations that report the same tax identification number in the National Provider Directory.

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1231372800000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1231372800000",
    "number": "1063659340",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "350 W WOODROW WILSON AVE",
            "address_2": "SUITE 615",
            "city": "JACKSON",
            "state": "MS",
            "postal_code": "392137681",
            "telephone_number": "601-982-0673",
            "fax_number": "601-982-0459"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "809 N STATE ST",
            "city": "JACKSON",
            "state": "MS",
            "postal_code": "392022604",
            "telephone_number": "601-982-0673",
            "fax_number": "601-982-0459"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "MALL SERVICES, LLC",
        "organizational_subpart": "NO",
        "enumeration_date": "2009-01-08",
        "last_updated": "2009-01-08",
        "status": "A",
        "authorized_official_last_name": "ROGERS",
        "authorized_official_first_name": "CHRISTAL",
        "authorized_official_title_or_position": "OFFICE ASSISTANT",
        "authorized_official_telephone_number": "601-982-0673",
        "authorized_official_name_prefix": "Mrs.",
        "authorized_official_credential": "LPN"
    },
    "taxonomies": [
        {
            "code": "172V00000X",
            "taxonomy_group": "193400000X MULTIPLE SINGLE SPECIALTY GROUP",
            "desc": "Community Health Worker",
            "state": "MS",
            "license": "P320574",
            "primary": false
        },
        {
            "code": "363LF0000X",
            "taxonomy_group": "193400000X MULTIPLE SINGLE SPECIALTY GROUP",
            "desc": "Nurse Practitioner, Family",
            "state": "MS",
            "license": "R656046",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "00115980",
            "state": "MS"
        },
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "08406271",
            "state": "MS"
        }
    ],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "809 Convenient Care Clinic",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

Other providers in Jackson, MS

Sources for this page

  • NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Jan 8, 2009; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
  • National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.