Healthcare Provider Details

I. General information

NPI: 1659318558
Provider Name (Legal Business Name): JACKSON HEART CLINIC. P.A.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/31/2006
Last Update Date: 04/10/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

970 LAKELAND DR SUITE 61
JACKSON MS
39216-4640
US

IV. Provider business mailing address

970 LAKELAND DR SUITE 61
JACKSON MS
39216-4640
US

V. Phone/Fax

Practice location:
  • Phone: 601-982-7850
  • Fax: 601-326-6278
Mailing address:
  • Phone: 601-982-7850
  • Fax: 601-326-6278

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License Number
License Number State

VIII. Authorized Official

Name: MS. STEPHANIE S EGGER
Title or Position: CEO
Credential:
Phone: 601-982-7850