Healthcare Provider Details

I. General information

NPI: 1154477453
Provider Name (Legal Business Name): ANTHONY WADE JACKSON SR. M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/27/2007
Last Update Date: 09/09/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

152 HIGHWAY 7 S
OXFORD MS
38655-5392
US

IV. Provider business mailing address

152 HIGHWAY 7 S
OXFORD MS
38655-5392
US

V. Phone/Fax

Practice location:
  • Phone: 662-488-8878
  • Fax:
Mailing address:
  • Phone: 662-488-8878
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0804X
TaxonomyChild & Adolescent Psychiatry Physician
License Number14917
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: