Healthcare Provider Details

I. General information

NPI: 1447577291
Provider Name (Legal Business Name): ST DOMINIC MEDICAL ASSOCIATES LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/03/2010
Last Update Date: 05/03/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

971 LAKELAND DR
JACKSON MS
39216-4643
US

IV. Provider business mailing address

971 LAKELAND DR
JACKSON MS
39216-4643
US

V. Phone/Fax

Practice location:
  • Phone: 601-200-6444
  • Fax: 601-200-6442
Mailing address:
  • Phone: 601-200-6444
  • Fax: 601-200-6442

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number1000032425
License Number StateMS

VIII. Authorized Official

Name: MS. JENNIFER SINCLAIR
Title or Position: CHIEF FINANCIAL OFFICER
Credential:
Phone: 601-200-2000