1093710089 NPI number — DR. TIMOTHY D JACKSON MD, SA-C

Table of content: DR. TIMOTHY D JACKSON MD, SA-C (NPI 1093710089)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1093710089 NPI number — DR. TIMOTHY D JACKSON MD, SA-C

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
JACKSON
Provider First Name:
TIMOTHY
Provider Middle Name:
D
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
MD, SA-C
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:
1093710089
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
09/30/2026
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 1810
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
GULFPORT
Provider Business Mailing Address State Name:
MS
Provider Business Mailing Address Postal Code:
39502-1810
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
228-575-1945
Provider Business Mailing Address Fax Number:
228-575-1964

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1397 BROAD AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
GULFPORT
Provider Business Practice Location Address State Name:
MS
Provider Business Practice Location Address Postal Code:
39501-2419
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
228-575-1945
Provider Business Practice Location Address Fax Number:
228-575-1964
Provider Enumeration Date:
06/16/2005

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: 207X00000X , with the licence number:  14510 , 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)





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