Healthcare Provider Details

I. General information

NPI: 1255992525
Provider Name (Legal Business Name): KACI JACKSON
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: KACI THOMPSON

II. Dates (important events)

Enumeration Date: 06/26/2019
Last Update Date: 08/27/2026
Certification Date: 08/27/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2406 HIGHWAY 45 N STE A
COLUMBUS MS
39705-1398
US

IV. Provider business mailing address

42465 HIGHWAY 195
HALEYVILLE AL
35565-7052
US

V. Phone/Fax

Practice location:
  • Phone: 662-329-9445
  • Fax: 662-329-9462
Mailing address:
  • Phone: 256-350-1764
  • Fax: 256-355-0884

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License NumberPT5726
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: