Provider Demographics
NPI:1902052962
Name:IMAGINE, LLC
Entity Type:Organization
Organization Name:IMAGINE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:BAXTER
Authorized Official - Middle Name:HUGH
Authorized Official - Last Name:HOGUE
Authorized Official - Suffix:
Authorized Official - Credentials:LPC
Authorized Official - Phone:601-259-4081
Mailing Address - Street 1:1920 DUNBARTON DR
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:MS
Mailing Address - Zip Code:39216-5001
Mailing Address - Country:US
Mailing Address - Phone:601-982-5376
Mailing Address - Fax:601-982-5377
Practice Address - Street 1:1920 DUNBARTON DR
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:MS
Practice Address - Zip Code:39216-5001
Practice Address - Country:US
Practice Address - Phone:601-982-5376
Practice Address - Fax:601-982-5377
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-08-11
Last Update Date:2023-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS1093101Y00000X
261QM0801X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)
No101Y00000XBehavioral Health & Social Service ProvidersCounselorGroup - Multi-Specialty