MEDICARE: JACKIE E. MCHENRY II M.D.

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	14485	MS

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	080185585	OTHER		RAILROAD MEDICARE

Other Identifiers

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

General Provider Information

NPI Number	:	1649252057
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JACKIE E. MCHENRY II M.D.

Provider Business Mailing Address
First Line	:	1111 N CAUSEWAY BLVD
Second Line	:
City	:	MANDEVILLE
State	:	LA
Zip	:	70471-3409
Country	:	US
Telephone Number	:	985-773-1844
Fax Number	:	985-893-8272

Provider Business Practice Location Address
First Line	:	140 BURKE CALHOUN CITY RD
Second Line	:
City	:	CALHOUN CITY
State	:	MS
Zip	:	38916
Country	:	US
Telephone Number	:	662-628-6300
Fax Number	:

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

Provider Enumeration Date	:	11/20/2005
Last Update Date	:	06/05/2018

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