Provider Demographics
NPI:1083853493
Name:ROGERS, JACK A JR
Entity Type:Individual
Prefix:
First Name:JACK
Middle Name:A
Last Name:ROGERS
Suffix:JR
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:152 HIGHWAY 7 S
Mailing Address - Street 2:
Mailing Address - City:OXFORD
Mailing Address - State:MS
Mailing Address - Zip Code:38655-5392
Mailing Address - Country:US
Mailing Address - Phone:662-234-7527
Mailing Address - Fax:662-236-3071
Practice Address - Street 1:152A HIGHWAY 7 S
Practice Address - Street 2:
Practice Address - City:OXFORD
Practice Address - State:MS
Practice Address - Zip Code:38655-5392
Practice Address - Country:US
Practice Address - Phone:662-234-7527
Practice Address - Fax:662-236-3071
Is Sole Proprietor?:No
Enumeration Date:2009-02-09
Last Update Date:2009-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS0035101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)