MEDICARE: JACKSON MEDICAL SUPPLY INC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	332B00000X	Durable Medical Equipment & Medical Supplies

General Provider Information

NPI Number	:	1386813806
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	JACKSON MEDICAL SUPPLY INC

Provider Business Mailing Address
First Line	:	2147 HENRY HILL DR
Second Line	:	STE 109
City	:	JACKSON
State	:	MS
Zip	:	39204-2001
Country	:	US
Telephone Number	:	601-923-3275
Fax Number	:

Provider Business Practice Location Address
First Line	:	2147 HENRY HILL DR
Second Line	:	STE 109
City	:	JACKSON
State	:	MS
Zip	:	39204-2001
Country	:	US
Telephone Number	:	601-923-3275
Fax Number	:

Authorized Official
Title or Position	:	PRESIDENT
Name	:	ALISA TEKHONOVA
Credential	:
Telephone Number	:	601-923-3275

Provider Enumeration Date	:	02/28/2008
Last Update Date	:	02/28/2008

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Directions to “JACKSON MEDICAL SUPPLY INC ” Practice Location

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