Healthcare Provider Details

I. General information

NPI: 1134706765
Provider Name (Legal Business Name): JACK GREGGORY THARP
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/28/2021
Last Update Date: 08/24/2026
Certification Date: 08/24/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1001 14TH ST
MERIDIAN MS
39301-4458
US

IV. Provider business mailing address

PO BOX 649105
DALLAS TX
75264-9105
US

V. Phone/Fax

Practice location:
  • Phone: 601-482-9224
  • Fax:
Mailing address:
  • Phone: 601-482-9224
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License NumberT-4361
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: