MEDICARE: JACKSON PUBLIC SCHOOLS DBA GALLOWAY 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	163W00000X	Registered Nurse	R857457	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	:	1710022959
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	JACKSON PUBLIC SCHOOLS DBA GALLOWAY CLINIC

Provider Business Mailing Address
First Line	:	662 S PRESIDENT ST
Second Line	:
City	:	JACKSON
State	:	MS
Zip	:	39201-5601
Country	:	US
Telephone Number	:	601-960-8705
Fax Number	:	601-960-8704

Provider Business Practice Location Address
First Line	:	186 IDLEWILD ST
Second Line	:
City	:	JACKSON
State	:	MS
Zip	:	39203-1219
Country	:	US
Telephone Number	:	601-360-2214
Fax Number	:	601-360-2212

Authorized Official
Title or Position	:	SUPERINTENDENT
Name	:	DR. EARL WATKINS
Credential	:	PH.D
Telephone Number	:	601-960-8700

Provider Enumeration Date	:	02/21/2007
Last Update Date	:	08/22/2020

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