1053322974 NPI number — PAUL D JACKSON MD

Table of content: PAUL D JACKSON MD (NPI 1053322974)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1053322974 NPI number — PAUL D JACKSON MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
JACKSON
Provider First Name:
PAUL
Provider Middle Name:
D
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1053322974
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
09/26/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 23998
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:
39225-3998
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
662-725-2749
Provider Business Mailing Address Fax Number:
662-725-2741

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
508 ARNOLD AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
GREENVILLE
Provider Business Practice Location Address State Name:
MS
Provider Business Practice Location Address Postal Code:
38701-5319
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
662-335-4000
Provider Business Practice Location Address Fax Number:
662-332-3867
Provider Enumeration Date:
08/10/2006

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: 207V00000X , with the licence number:  09542 , 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: P00386728 . This is a "RR MEDICARE" identifier . This identifiers is of the category "OTHER".
  • Identifier: 00011234 , issued by the state of ( MS ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1528005 , issued by the state of ( LA ) . This identifiers is of the category "MEDICAID".