Healthcare Provider Details

I. General information

NPI: 1487664173
Provider Name (Legal Business Name): JO LYNN POLK M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/08/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4798 MCWILLIE DR SUITE C
JACKSON MS
39206-5608
US

IV. Provider business mailing address

4798 MCWILLIE DR SUITE C
JACKSON MS
39206-5608
US

V. Phone/Fax

Practice location:
  • Phone: 601-362-7649
  • Fax:
Mailing address:
  • Phone: 601-362-7649
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208100000X
TaxonomyPhysical Medicine & Rehabilitation Physician
License Number08790
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: