Provider Demographics
NPI:1770901688
Name:METHODIST CHILDREN'S HOMES
Entity type:Organization
Organization Name:METHODIST CHILDREN'S HOMES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:VICE PRESIDENT OF PROGRAMS
Authorized Official - Prefix:MR
Authorized Official - First Name:DEVON
Authorized Official - Middle Name:
Authorized Official - Last Name:LOGGINS
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:601-853-5000
Mailing Address - Street 1:805 N FLAG CHAPEL RD
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:MS
Mailing Address - Zip Code:39209-2208
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:805 N FLAG CHAPEL RD
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:MS
Practice Address - Zip Code:39209-2208
Practice Address - Country:US
Practice Address - Phone:601-853-5000
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-03-29
Last Update Date:2014-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS322D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes322D00000XResidential Treatment FacilitiesResidential Treatment Facility, Emotionally Disturbed Children
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS03078895Medicaid