Provider Demographics
NPI:1083328157
Name:JACKSON, BEATRICE GALE
Entity Type:Individual
Prefix:
First Name:BEATRICE
Middle Name:GALE
Last Name:JACKSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4100 MAGNOLIA ST
Mailing Address - Street 2:
Mailing Address - City:MOSS POINT
Mailing Address - State:MS
Mailing Address - Zip Code:39563-4104
Mailing Address - Country:US
Mailing Address - Phone:228-627-2805
Mailing Address - Fax:
Practice Address - Street 1:4100 MAGNOLIA ST
Practice Address - Street 2:
Practice Address - City:MOSS POINT
Practice Address - State:MS
Practice Address - Zip Code:39563-4104
Practice Address - Country:US
Practice Address - Phone:228-627-2805
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-01-12
Last Update Date:2023-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes343900000XTransportation ServicesNon-emergency Medical Transport (VAN)