Provider Demographics
NPI:1093934002
Name:JACKSON EAR CLINIC PA
Entity Type:Organization
Organization Name:JACKSON EAR CLINIC PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:KATHY
Authorized Official - Middle Name:
Authorized Official - Last Name:PEEPLES
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:601-981-2825
Mailing Address - Street 1:290 E LAYFAIR DR
Mailing Address - Street 2:
Mailing Address - City:FLOWOOD
Mailing Address - State:MS
Mailing Address - Zip Code:39232-9526
Mailing Address - Country:US
Mailing Address - Phone:601-981-2825
Mailing Address - Fax:601-981-2827
Practice Address - Street 1:290 E LAYFAIR DR
Practice Address - Street 2:
Practice Address - City:FLOWOOD
Practice Address - State:MS
Practice Address - Zip Code:39232-9526
Practice Address - Country:US
Practice Address - Phone:601-981-2825
Practice Address - Fax:601-981-2827
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-25
Last Update Date:2020-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS11369174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS04586854Medicaid
MSD80498Medicare UPIN
MS04586854Medicaid