MEDICARE: JACKSON PUBLIC SCHOOLS LANIER CLINIC

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
1	261Q00000X	Clinic/Center

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1326221300
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	JACKSON PUBLIC SCHOOLS LANIER CLINIC

Provider Business Mailing Address
First Line	:	618 S PRESIDENT ST
Second Line	:
City	:	JACKSON
State	:	MS
Zip	:	39201-5601
Country	:	US
Telephone Number	:	601-209-4456
Fax Number	:

Provider Business Practice Location Address
First Line	:	833 MAPLE ST
Second Line	:
City	:	JACKSON
State	:	MS
Zip	:	39203-3844
Country	:	US
Telephone Number	:	601-209-4456
Fax Number	:	601-960-8704

Authorized Official
Title or Position	:	LEAD NURSE
Name	:	MRS. TAMMY D CROCKER
Credential	:	R.N.
Telephone Number	:	601-209-4456

Provider Enumeration Date	:	12/12/2007
Last Update Date	:	12/12/2007

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