Healthcare Provider Details

I. General information

NPI: 1720317688
Provider Name (Legal Business Name): GARY HOWARD JACKSON M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/23/2009
Last Update Date: 12/23/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

38 BENT PEBBLE PT
LUMBERTON MS
39455-9037
US

IV. Provider business mailing address

38 BENT PEBBLE PT
LUMBERTON MS
39455-9037
US

V. Phone/Fax

Practice location:
  • Phone: 601-794-8081
  • Fax: 601-794-8081
Mailing address:
  • Phone: 601-794-8081
  • Fax: 601-794-8081

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License Number07677
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: