MEDICARE: DR. JACK C EVANS MD

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	207Q00000X	Family Medicine Physician	09103	MS

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	:	1396784187
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. JACK C EVANS MD

Provider Business Mailing Address
First Line	:	PO BOX 247
Second Line	:
City	:	LAUREL
State	:	MS
Zip	:	39441-0247
Country	:	US
Telephone Number	:	601-399-6167
Fax Number	:	601-399-6281

Provider Business Practice Location Address
First Line	:	1440 JEFFERSON ST
Second Line	:
City	:	LAUREL
State	:	MS
Zip	:	39440-4243
Country	:	US
Telephone Number	:	601-428-0577
Fax Number	:	601-649-7962

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/06/2006
Last Update Date	:	02/11/2014

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