Provider Demographics
NPI:1164151247
Name:JACKSON, CALLEN DEYOUNG (DMD)
Entity Type:Individual
Prefix:
First Name:CALLEN
Middle Name:DEYOUNG
Last Name:JACKSON
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2139 HIGHWAY 471
Mailing Address - Street 2:
Mailing Address - City:BRANDON
Mailing Address - State:MS
Mailing Address - Zip Code:39047-8748
Mailing Address - Country:US
Mailing Address - Phone:769-241-5807
Mailing Address - Fax:
Practice Address - Street 1:2139 HIGHWAY 471
Practice Address - Street 2:
Practice Address - City:BRANDON
Practice Address - State:MS
Practice Address - Zip Code:39047-8748
Practice Address - Country:US
Practice Address - Phone:769-241-5807
Practice Address - Fax:769-241-5805
Is Sole Proprietor?:No
Enumeration Date:2022-06-06
Last Update Date:2022-06-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS4276-221223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice