Provider Demographics
NPI:1144614165
Name:JACKSON, RANDALL (CFNP)
Entity Type:Individual
Prefix:
First Name:RANDALL
Middle Name:
Last Name:JACKSON
Suffix:
Gender:M
Credentials:CFNP
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 490
Mailing Address - Street 2:
Mailing Address - City:MCCOMB
Mailing Address - State:MS
Mailing Address - Zip Code:39649-0490
Mailing Address - Country:US
Mailing Address - Phone:601-249-2701
Mailing Address - Fax:601-249-2195
Practice Address - Street 1:215 MARION AVE
Practice Address - Street 2:
Practice Address - City:MCCOMB
Practice Address - State:MS
Practice Address - Zip Code:39648-2705
Practice Address - Country:US
Practice Address - Phone:601-249-5500
Practice Address - Fax:601-249-1173
Is Sole Proprietor?:No
Enumeration Date:2015-03-27
Last Update Date:2022-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSR878547363LF0000X
MS878547363LA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS05435530Medicaid
MS403380YYL1Medicare PIN