Healthcare Provider Details

I. General information

NPI: 1487067328
Provider Name (Legal Business Name): GREATER JACKSON PHYSICIAN GROUP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/09/2014
Last Update Date: 07/21/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

501 MARSHALL ST STE 501
JACKSON MS
39202-1615
US

IV. Provider business mailing address

501 MARSHALL ST STE 501
JACKSON MS
39202-1615
US

V. Phone/Fax

Practice location:
  • Phone: 601-968-0985
  • Fax: 601-960-0583
Mailing address:
  • Phone: 601-899-3990
  • Fax: 601-960-0583

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License Number
License Number State

VIII. Authorized Official

Name: MRS. LINDA M SWILLEY
Title or Position: OWNER
Credential:
Phone: 601-968-0985