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NPI Code Detail

MEDICARE: DR. TIMOTHY D JACKSON MD, SA-C

MEDICARE: DR. TIMOTHY D JACKSON MD, SA-C
Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

# Taxonomy Code Taxonomy License Number License Number State
1207X00000XOrthopaedic Surgery Physician14510MS
2246ZC0007XSurgical Assistant19-516

General Provider Information

NPI Number : 1093710089
Entity Type Code : Individual
Provider Name (Legal Business Name) : DR. TIMOTHY D JACKSON MD, SA-C
Provider Business Mailing Address
First Line : 15520 DANIEL BLVD # 310
Second Line :
City : GULFPORT
State : MS
Zip : 39503-4735
Country : US
Telephone Number : 228-304-9436
Fax Number :
Provider Business Practice Location Address
First Line : 4500 13TH ST
Second Line :
City : GULFPORT
State : MS
Zip : 39501-2515
Country : US
Telephone Number : 228-304-9436
Fax Number :
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 06/16/2005
Last Update Date : 01/14/2026

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