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General NPI Number Information
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NPI Number | 1154956134
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Entity Type | Organization
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Legal Business Name | GREATER JACKSON OBGYN LLC
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Dates
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Enumeration Date | 03/10/2020
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Last Update Date | 11/23/2020
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Provider Practice Location Address
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Address Line | 501 MARSHALL ST STE 502
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City | JACKSON
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State | MS
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Zip | 39202-1661
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Country | US
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Telephone | 769-233-8585
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Fax | 601-487-5156
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Provider Business Mailing Address
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Address Line | 501 MARSHALL ST STE 502
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City | JACKSON
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State | MS
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Zip | 39202-1661
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Country | US
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Telephone | 769-233-8585
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Fax | 601-487-5153
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Authorized Official
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Title or Position | OFFICE MANAGER
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Name | DEBRA AMY MARTIN
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Credential |
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Telephone | 769-233-8585
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207V00000X
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Taxonomy Name | Obstetrics & Gynecology Physician
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License Number |
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License Number State |
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