Healthcare Provider Details

I. General information

NPI: 1194631044
Provider Name (Legal Business Name): CARLY JANE JACKSON PA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/20/2026
Last Update Date: 08/20/2026
Certification Date: 08/20/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2925 LAYFAIR DR
FLOWOOD MS
39232-9507
US

IV. Provider business mailing address

1156 GUNTER RD
FLORENCE MS
39073-9705
US

V. Phone/Fax

Practice location:
  • Phone: 601-984-5314
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: