Healthcare Provider Details

I. General information

NPI: 1114421021
Provider Name (Legal Business Name): MAGNOLIA MEDICAL FOUNDATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/23/2018
Last Update Date: 03/23/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1230 RAYMOND RD STE 600
JACKSON MS
39204-4579
US

IV. Provider business mailing address

1230 RAYMOND RD STE 600
JACKSON MS
39204-4579
US

V. Phone/Fax

Practice location:
  • Phone: 601-613-3737
  • Fax:
Mailing address:
  • Phone: 601-613-3737
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174H00000X
TaxonomyHealth Educator
License Number
License Number State

VIII. Authorized Official

Name: DR. ERICA THOMPSON
Title or Position: EXECUTIVE DIRECTOR
Credential:
Phone: 601-613-3737