Healthcare Provider Details

I. General information

NPI: 1225105315
Provider Name (Legal Business Name): JACKSON LUNG CLINIC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/30/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1151 N STATE ST SUITE 301
JACKSON MS
39202-2407
US

IV. Provider business mailing address

PO BOX 967
JACKSON MS
39205-0967
US

V. Phone/Fax

Practice location:
  • Phone: 601-352-0041
  • Fax: 601-352-0043
Mailing address:
  • Phone: 601-936-6001
  • Fax: 601-936-4389

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: WILLIAM FRAZIER
Title or Position: MANAGING OWNER
Credential: MD
Phone: 601-936-6001