Healthcare Provider Details

I. General information

NPI: 1740971142
Provider Name (Legal Business Name): JACOB KELVIN SIMMONS MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/16/2023
Last Update Date: 10/07/2026
Certification Date: 10/07/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1220 JEFFERSON ST
LAUREL MS
39440-4355
US

IV. Provider business mailing address

PO BOX 247
LAUREL MS
39441-0247
US

V. Phone/Fax

Practice location:
  • Phone: 601-649-2863
  • Fax: 601-649-9479
Mailing address:
  • Phone: 601-399-6169
  • Fax: 601-399-6281

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number37699
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: