1528148483 NPI number — DR. MELINDA MULLINS JACKSON M. D.

Table of content: DR. MELINDA MULLINS JACKSON M. D. (NPI 1528148483)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1528148483 NPI number — DR. MELINDA MULLINS JACKSON M. D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
JACKSON
Provider First Name:
MELINDA
Provider Middle Name:
MULLINS
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
M. D.
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
MULLINS
Provider Other First Name:
MELINDA
Provider Other Middle Name:
CHARLENE
Provider Other Name Prefix Text:
DR.
Provider Other Name Suffix Text:
Provider Other Credential Text:
M. D.
Provider Other Last Name Type Code:
2

NPI Number Information

NPI Number:
1528148483
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/21/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4641 MAUREY RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
JACKSON
Provider Business Mailing Address State Name:
MS
Provider Business Mailing Address Postal Code:
39211-5625
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
601-594-6006
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
701 NORTHSIDE DRIVE
Provider Second Line Business Practice Location Address:
CENTRAL MISSISSIPPI RESIDENTIAL CENTER
Provider Business Practice Location Address City Name:
NEWTON
Provider Business Practice Location Address State Name:
MS
Provider Business Practice Location Address Postal Code:
36345-2361
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
601-683-4200
Provider Business Practice Location Address Fax Number:
601-683-4269
Provider Enumeration Date:
10/16/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 207R00000X , with the licence number:  11594 , registered in the state of MS ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 2084P0800X , with the licence number: 11594 , registered in the state of MS ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 00018302 , issued by the state of ( MS ) . This identifiers is of the category "MEDICAID".




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