| Southeastern Psychology Group | |
|
3006 Greystone Sq Jackson TN 38305-3589 | |
| (731) 474-1242 | |
| Not Available |
| Full Name | Southeastern Psychology Group |
|---|---|
| Speciality | Clinic/Center |
| Location | 3006 Greystone Sq, Jackson, Tennessee |
| Authorized Official Name and Position | Joseph Fouche (OWNER) |
| Authorized Official Contact | 2168328294 |
| Accepts Medicare Insurance | Yes. This clinic participates in medicare program and accept medicare insurance. |
| Mailing Address | Practice Location Address |
|---|---|
| Southeastern Psychology Group 3006 Greystone Sq Jackson TN 38305-3589 Ph: (860) 230-6947 | Southeastern Psychology Group 3006 Greystone Sq Jackson TN 38305-3589 Ph: (731) 474-1242 |
| NPI Number | 1043974728 |
|---|---|
| Provider Enumeration Date | 10/28/2021 |
| Last Update Date | 06/29/2022 |
| Certification Date | 06/29/2022 |
| Medicare PECOS PAC ID | 3971983461 |
|---|---|
| Medicare Enrollment ID | O20220629003615 |
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 1043974728 | NPI | - | NPPES |
| Taxonomy | Type | License (State) | Status |
|---|---|---|---|
| 261QM0801X | Clinic/center - Mental Health (including Community Mental Health Center) | (* (Not Available)) | Primary |
| Provider Name | Sophia Fouche |
|---|---|
| Provider Type | Practitioner - Psychologist Billing Independently |
| Provider Identifiers | NPI Number: 1871995977 PECOS PAC ID: 7911226683 Enrollment ID: I20150430000944 |
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