Healthcare Provider Details

I. General information

NPI: 1477428852
Provider Name (Legal Business Name): MEGAN MASCARO
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: MEGAN COTHERN

II. Dates (important events)

Enumeration Date: 10/07/2025
Last Update Date: 07/06/2026
Certification Date: 07/06/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2500 N STATE ST
JACKSON MS
39216-4500
US

IV. Provider business mailing address

2500 N STATE ST
JACKSON MS
39216-4500
US

V. Phone/Fax

Practice location:
  • Phone: 601-984-5012
  • Fax:
Mailing address:
  • Phone: 601-984-5012
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License NumberT-6161
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: