Healthcare Provider Details

I. General information

NPI: 1134662646
Provider Name (Legal Business Name): STEVIE JACKSON NP-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/01/2016
Last Update Date: 03/17/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1007 W CONGRESS ST
BROOKHAVEN MS
39601-2603
US

IV. Provider business mailing address

1827 SIMPSON HIGHWAY 149
MENDENHALL MS
39114-3439
US

V. Phone/Fax

Practice location:
  • Phone: 601-847-3712
  • Fax:
Mailing address:
  • Phone: 601-894-6669
  • Fax: 601-894-4721

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number901629
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: