1154549707 NPI number — CENTRAL JACKSON FAMILY MEDICAL CLINIC

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1154549707 NPI number — CENTRAL JACKSON FAMILY MEDICAL CLINIC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
CENTRAL JACKSON FAMILY MEDICAL CLINIC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

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:
1154549707
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
12/09/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
P.O. BOX 4610
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:
39296-4610
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
601-981-7198
Provider Business Mailing Address Fax Number:
601-981-6616

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
514 C WOODROW WILSON
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
JACKSON
Provider Business Practice Location Address State Name:
MS
Provider Business Practice Location Address Postal Code:
39216
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
601-981-7198
Provider Business Practice Location Address Fax Number:
601-981-6616
Provider Enumeration Date:
04/20/2007

Additional Information

Authorized Official

Authorized Official Last Name:
THOMAS
Authorized Official First Name:
CASSANDRA
Authorized Official Middle Name:
FAYE
Authorized Official Title or Position:
PHYSICAIN
Authorized Official Telephone Number:
601-981-7198

Provider Taxonomy Codes

  • Taxonomy code: 261QM2500X , with the licence number:  18905 , registered in the state of MS ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 261QM2500X , with the licence number: 13653 , 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: 00937242 , issued by the state of ( MS ) . This identifiers is of the category "MEDICAID".
  • Identifier: 00112137 , issued by the state of ( MS ) . This identifiers is of the category "MEDICAID".




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