Healthcare Provider Details

I. General information

NPI: 1578942892
Provider Name (Legal Business Name): JORDAN THIESEN
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/19/2015
Last Update Date: 07/11/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2500 N STATE ST DEPARTMENT OF EMERGENCY MEDICINE
JACKSON MS
39216
US

IV. Provider business mailing address

2500 N STATE ST DEPARTMENT OF EMERGENCY MEDICINE
JACKSON MS
39216-4500
US

V. Phone/Fax

Practice location:
  • Phone: 601-984-5582
  • Fax: 601-984-5583
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number20A16372
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: