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General NPI Number Information
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NPI Number | 1538361118
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Entity Type | Organization
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Legal Business Name | H.S. JACKSON JR. PSC
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Dates
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Enumeration Date | 06/05/2007
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Last Update Date | 12/21/2010
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Provider Practice Location Address
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Address Line | 300 S 8TH ST SUITE 107E
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City | MURRAY
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State | KY
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Zip | 42071-2400
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Country | US
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Telephone | 270-753-9240
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Fax | 270-767-3629
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Provider Business Mailing Address
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Address Line | 300 S 8TH ST SUITE 107E
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City | MURRAY
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State | KY
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Zip | 42071-2400
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Country | US
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Telephone | 270-753-9240
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Fax | 270-767-3629
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Authorized Official
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Title or Position | PRESIDENT
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Name | HERSCHEL SWAN JACKSON JR.
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Credential | M.D.
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Telephone | 270-753-9240
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 363LF0000X
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Taxonomy Name | Family Nurse Practitioner
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License Number | 5519P
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License Number State | KY
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Taxonomy #2
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Taxonomy Code | 208800000X
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Taxonomy Name | Urology Physician
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License Number | 15974
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License Number State | KY
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