=====================================================
General NPI Number Information
=====================================================
NPI Number | 1720575392
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | HOLLY JACKSON CRNA
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/18/2018
-----------------------------------------------------
Last Update Date | 09/23/2026
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 7601 SOUTHCREST PKWY
-----------------------------------------------------
City | SOUTHAVEN
-----------------------------------------------------
State | MS
-----------------------------------------------------
Zip | 38671-4739
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 662-772-4333
-----------------------------------------------------
Fax | 855-999-1345
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 7956 VAUGHN RD STE 165
-----------------------------------------------------
City | MONTGOMERY
-----------------------------------------------------
State | AL
-----------------------------------------------------
Zip | 36116-6819
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 888-233-1493
-----------------------------------------------------
Fax | 855-999-1345
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 367500000X
-----------------------------------------------------
Taxonomy Name | Certified Registered Nurse Anesthetist
-----------------------------------------------------
License Number | 901371
-----------------------------------------------------
License Number State | MS
-----------------------------------------------------