Healthcare Provider Details

I. General information

NPI: 1982702155
Provider Name (Legal Business Name): JACKSON SCOTT THOMAS MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/20/2006
Last Update Date: 01/13/2025
Certification Date: 01/13/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2124 14TH ST
MERIDIAN MS
39301-4040
US

IV. Provider business mailing address

965 RIDGE LAKE BLVD STE 315
MEMPHIS TN
38120-9401
US

V. Phone/Fax

Practice location:
  • Phone: 601-553-6000
  • Fax: 601-703-0124
Mailing address:
  • Phone: 877-348-1281
  • Fax: 901-227-3206

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number15444
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: