Provider Demographics
NPI:1033131487
Name:POLK, JASON L (D M D)
Entity Type:Individual
Prefix:DR
First Name:JASON
Middle Name:L
Last Name:POLK
Suffix:
Gender:M
Credentials:D M D
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 180607
Mailing Address - Street 2:
Mailing Address - City:RICHLAND
Mailing Address - State:MS
Mailing Address - Zip Code:39218-0607
Mailing Address - Country:US
Mailing Address - Phone:601-932-0606
Mailing Address - Fax:601-932-0703
Practice Address - Street 1:120 SCARBROUGH ST
Practice Address - Street 2:SUITE B
Practice Address - City:RICHLAND
Practice Address - State:MS
Practice Address - Zip Code:39218-9770
Practice Address - Country:US
Practice Address - Phone:601-932-0606
Practice Address - Fax:601-932-0703
Is Sole Proprietor?:No
Enumeration Date:2006-07-24
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS31371223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00660432Medicaid
MS00660433Medicaid
MS09016079Medicaid