Provider Demographics
NPI:1538263835
Name:REID, JO ELLEN (LCSW)
Entity type:Individual
Prefix:MRS
First Name:JO ELLEN
Middle Name:
Last Name:REID
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 7827
Mailing Address - Street 2:
Mailing Address - City:GULFPORT
Mailing Address - State:MS
Mailing Address - Zip Code:39506-7827
Mailing Address - Country:US
Mailing Address - Phone:228-897-7730
Mailing Address - Fax:228-897-2121
Practice Address - Street 1:319 COURTHOUSE ROAD
Practice Address - Street 2:SUITES B AND C
Practice Address - City:GULFPORT
Practice Address - State:MS
Practice Address - Zip Code:39507
Practice Address - Country:US
Practice Address - Phone:228-897-7730
Practice Address - Fax:228-897-2121
Is Sole Proprietor?:No
Enumeration Date:2006-09-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSC10051041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
525296Medicare UPIN