Healthcare Provider Details

I. General information

NPI: 1811931454
Provider Name (Legal Business Name): DR. JOY JACKSON
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/15/2006
Last Update Date: 02/28/2020
Certification Date: 02/28/2020
Deactivation Date: 02/10/2020
Reactivation Date: 02/28/2020

III. Provider practice location address

3502 W NORTHSIDE DR
JACKSON MS
39213-4454
US

IV. Provider business mailing address

3502 W NORTHSIDE DR
JACKSON MS
39213-4454
US

V. Phone/Fax

Practice location:
  • Phone: 601-362-5321
  • Fax: 601-364-2600
Mailing address:
  • Phone: 601-362-5321
  • Fax: 601-364-2600

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number11626
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: