Provider Demographics
NPI:1164576476
Name:JACKSON, RUSSELL EARL
Entity Type:Individual
Prefix:MR
First Name:RUSSELL
Middle Name:EARL
Last Name:JACKSON
Suffix:
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:PO BOX 1943
Mailing Address - Street 2:
Mailing Address - City:VERONA
Mailing Address - State:MS
Mailing Address - Zip Code:38879-1943
Mailing Address - Country:US
Mailing Address - Phone:662-566-7969
Mailing Address - Fax:
Practice Address - Street 1:920 BOONE ST
Practice Address - Street 2:
Practice Address - City:TUPELO
Practice Address - State:MS
Practice Address - Zip Code:38804-5908
Practice Address - Country:US
Practice Address - Phone:662-844-3531
Practice Address - Fax:662-844-1757
Is Sole Proprietor?:No
Enumeration Date:2007-01-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)