Provider Demographics
NPI:1174247647
Name:CLAXTON, ILYSSA (CCSS)
Entity type:Individual
Prefix:
First Name:ILYSSA
Middle Name:
Last Name:CLAXTON
Suffix:
Gender:F
Credentials:CCSS
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 18679
Mailing Address - Street 2:
Mailing Address - City:HATTIESBURG
Mailing Address - State:MS
Mailing Address - Zip Code:39404-8679
Mailing Address - Country:US
Mailing Address - Phone:601-705-1901
Mailing Address - Fax:601-705-1952
Practice Address - Street 1:110 PATTON AVE
Practice Address - Street 2:
Practice Address - City:HATTIESBURG
Practice Address - State:MS
Practice Address - Zip Code:39401-6155
Practice Address - Country:US
Practice Address - Phone:601-582-1111
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-09-28
Last Update Date:2022-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS2938171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator