Healthcare Provider Details

I. General information

NPI: 1154753986
Provider Name (Legal Business Name): JACKSON HAND AND UPPER EXTREMITY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/02/2013
Last Update Date: 07/08/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1904 LAKELAND DR SUITE D
JACKSON MS
39216-5038
US

IV. Provider business mailing address

1904 LAKELAND DR SUITE D
JACKSON MS
39216-5038
US

V. Phone/Fax

Practice location:
  • Phone: 601-942-2709
  • Fax: 601-944-9780
Mailing address:
  • Phone: 601-942-2709
  • Fax: 601-944-9780

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License NumberPT0987
License Number StateMS
# 2
Primary TaxonomyY
Taxonomy Code225XH1200X
TaxonomyHand Occupational Therapist
License Number45OT073
License Number StateMS

VIII. Authorized Official

Name: ROBYN ROBERTS
Title or Position: OWNER
Credential: PT
Phone: 601-942-2709