Healthcare Provider Details

I. General information

NPI: 1174570584
Provider Name (Legal Business Name): JACKSON PULMONARY ASSOCIATES, PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/30/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

971 LAKELAND DR SUITE 1052
JACKSON MS
39216-4643
US

IV. Provider business mailing address

971 LAKELAND DR SUITE 1052
JACKSON MS
39216-4643
US

V. Phone/Fax

Practice location:
  • Phone: 601-981-9503
  • Fax: 601-982-0148
Mailing address:
  • Phone: 601-981-9503
  • Fax: 601-982-0148

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RP1001X
TaxonomyPulmonary Disease Physician
License Number
License Number State

VIII. Authorized Official

Name: R TODD WARREN
Title or Position: ADMINISTRATOR
Credential:
Phone: 601-321-1183