Healthcare Provider Details

I. General information

NPI: 1831473552
Provider Name (Legal Business Name): JACKIE CLANTON MCDONALD DNP-C
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/29/2011
Last Update Date: 03/30/2026
Certification Date: 03/30/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10 PROVENCE BLVD
MADISON MS
39110-8350
US

IV. Provider business mailing address

10 PROVENCE BLVD
MADISON MS
39110-8350
US

V. Phone/Fax

Practice location:
  • Phone: 601-608-7213
  • Fax: 601-608-7213
Mailing address:
  • Phone: 601-608-7213
  • Fax: 601-608-7213

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberR863322
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: