Healthcare Provider Details

I. General information

NPI: 1215159793
Provider Name (Legal Business Name): JACKSON ASTHMA & ALLERGY CENTER, PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/03/2007
Last Update Date: 05/22/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5903 RIDGEWOOD ROAD SUITE 430
JACKSON MS
39211-3702
US

IV. Provider business mailing address

5903 RIDGEWOOD ROAD SUITE 430
JACKSON MS
39211-3702
US

V. Phone/Fax

Practice location:
  • Phone: 601-899-3450
  • Fax: 601-899-3453
Mailing address:
  • Phone: 601-899-3450
  • Fax: 601-899-3453

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207K00000X
TaxonomyAllergy & Immunology Physician
License Number06707
License Number StateMS

VIII. Authorized Official

Name: MS. DONNA L PRICE
Title or Position: OFFICE MANAGER
Credential:
Phone: 601-899-3450