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General NPI Number Information
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NPI Number | 1740742329
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Entity Type | Organization
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Legal Business Name | JACKSONBRACEY HEALTH CARE
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Dates
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Enumeration Date | 04/03/2019
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Last Update Date | 04/03/2019
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Provider Practice Location Address
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Address Line | 4490 US-80
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City | PEARL
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State | MS
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Zip | 39208
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Country | US
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Telephone | 601-383-1977
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Fax |
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Provider Business Mailing Address
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Address Line | 4490 HIGHWAY 80 E
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City | PEARL
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State | MS
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Zip | 39208-4213
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position | OFFICE STAFF
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Name | KRISTEN LILES
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Credential |
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Telephone | 601-937-5415
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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 |
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License Number State |
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