Basic Information
| Provider Information | |||||||||
| NPI: | 1033877543 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | HOLDER | ||||||||
| FirstName: | GIGI | ||||||||
| MiddleName: | RENEE | ||||||||
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| Credential: | LCSW | ||||||||
| OtherOrganizationName: | |||||||||
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| OtherLastName: | HOLDER | ||||||||
| OtherFirstName: | GIGI | ||||||||
| OtherMiddleName: | R | ||||||||
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| OtherCredential: | LCSW | ||||||||
| OtherLastNameType: | 5 | ||||||||
| Mailing Information | |||||||||
| Address1: | 504 CLINTON CENTER DRIVE | ||||||||
| Address2: | STE. 4300 | ||||||||
| City: | CLINTON | ||||||||
| State: | MS | ||||||||
| PostalCode: | 390565610 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6014969413 | ||||||||
| FaxNumber: | 6018150434 | ||||||||
| Practice Location | |||||||||
| Address1: | 4400 OLD CANTON ROAD | ||||||||
| Address2: | 3RD FLOOR | ||||||||
| City: | JACKSON | ||||||||
| State: | MS | ||||||||
| PostalCode: | 39211 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6018152005 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/01/2021 | ||||||||
| LastUpdateDate: | 12/02/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 12/02/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041C0700X | C9395 | MS | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical |
No ID Information.