Healthcare Provider Details

I. General information

NPI: 1144614165
Provider Name (Legal Business Name): RANDALL JACKSON CFNP
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/27/2015
Last Update Date: 05/02/2022
Certification Date: 05/02/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

215 MARION AVE
MCCOMB MS
39648-2705
US

IV. Provider business mailing address

PO BOX 490
MCCOMB MS
39649-0490
US

V. Phone/Fax

Practice location:
  • Phone: 601-249-5500
  • Fax: 601-249-1173
Mailing address:
  • Phone: 601-249-2701
  • Fax: 601-249-2195

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberR878547
License Number StateMS
# 2
Primary TaxonomyY
Taxonomy Code363LA2100X
TaxonomyAcute Care Nurse Practitioner
License Number878547
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: