Healthcare Provider Details

I. General information

NPI: 1316975287
Provider Name (Legal Business Name): JACKSON RURAL HEALTH CLINIC P A
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/29/2006
Last Update Date: 12/04/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

29 S FOURTH ST
ROLLING FORK MS
39159-5146
US

IV. Provider business mailing address

PO BOX 520
ROLLING FORK MS
39159-0520
US

V. Phone/Fax

Practice location:
  • Phone: 662-873-4361
  • Fax: 662-873-2921
Mailing address:
  • Phone: 662-873-4361
  • Fax: 662-873-2921

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number253949
License Number StateMS

VIII. Authorized Official

Name: DR. DANNY JACKSON
Title or Position: OWNER
Credential: D.O.
Phone: 662-873-4361