Healthcare Provider Details

I. General information

NPI: 1659304301
Provider Name (Legal Business Name): DR. DANNY W JACKSON D.O. PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/08/2006
Last Update Date: 08/22/2020
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 Code291U00000X
TaxonomyClinical Medical Laboratory
License Number
License Number StateMS

VIII. Authorized Official

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