Healthcare Provider Details

I. General information

NPI: 1306876065
Provider Name (Legal Business Name): ST DOMINIC-JACKSON MEMORIAL HOSPITAL
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/05/2006
Last Update Date: 09/18/2025
Certification Date: 09/18/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

969 LAKELAND DR
JACKSON MS
39216-4606
US

IV. Provider business mailing address

969 LAKELAND DR
JACKSON MS
39216-4606
US

V. Phone/Fax

Practice location:
  • Phone: 601-200-2000
  • Fax: 601-200-0924
Mailing address:
  • Phone: 601-200-2000
  • Fax: 601-200-0924

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code282N00000X
TaxonomyGeneral Acute Care Hospital
License Number14-031
License Number StateMS

VIII. Authorized Official

Name: SAMUEL THADDEUS SCOTT II
Title or Position: CFO
Credential:
Phone: 601-200-6570