Healthcare Provider Details

I. General information

NPI: 1659556298
Provider Name (Legal Business Name): JACKSON PEDIATRIC ASSOCIATES P A
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/02/2008
Last Update Date: 11/15/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1824 HOSPITAL DR
JACKSON MS
39204-3410
US

IV. Provider business mailing address

297 HIGHWAY 51 STE B
RIDGELAND MS
39157-3423
US

V. Phone/Fax

Practice location:
  • Phone: 601-346-4586
  • Fax: 601-346-4587
Mailing address:
  • Phone: 601-707-5381
  • Fax: 601-737-5382

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number12555
License Number StateMS

VIII. Authorized Official

Name: DR. YOLANDA W WILSON
Title or Position: PRESIDENT
Credential: M.D.
Phone: 601-707-5381