Healthcare Provider Details

I. General information

NPI: 1538361118
Provider Name (Legal Business Name): H.S. JACKSON JR. PSC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/05/2007
Last Update Date: 12/21/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

300 S 8TH ST SUITE 107E
MURRAY KY
42071-2400
US

IV. Provider business mailing address

300 S 8TH ST SUITE 107E
MURRAY KY
42071-2400
US

V. Phone/Fax

Practice location:
  • Phone: 270-753-9240
  • Fax: 270-767-3629
Mailing address:
  • Phone: 270-753-9240
  • Fax: 270-767-3629

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208800000X
TaxonomyUrology Physician
License Number15974
License Number StateKY
# 2
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number5519P
License Number StateKY

VIII. Authorized Official

Name: HERSCHEL SWAN JACKSON JR.
Title or Position: PRESIDENT
Credential: M.D.
Phone: 270-753-9240