Healthcare Provider Details

I. General information

NPI: 1215994231
Provider Name (Legal Business Name): RICHARD JACKSON MD
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 04/26/2006
Last Update Date: 07/21/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1400 E UNION ST
GREENVILLE MS
38703-3246
US

IV. Provider business mailing address

PO BOX 235019
MONTGOMERY AL
36123-5019
US

V. Phone/Fax

Practice location:
  • Phone: 662-378-3783
  • Fax:
Mailing address:
  • Phone: 334-279-1450
  • Fax: 334-279-1660

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License Number17867
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: