Provider Demographics
NPI:1376727388
Name:JACKSON, JACQUENETT
Entity Type:Individual
Prefix:MRS
First Name:JACQUENETT
Middle Name:
Last Name:JACKSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:ANNETTE
Other - Middle Name:
Other - Last Name:SMITH
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 462
Mailing Address - Street 2:
Mailing Address - City:SHUBUTA
Mailing Address - State:MS
Mailing Address - Zip Code:39360-0462
Mailing Address - Country:US
Mailing Address - Phone:601-687-1128
Mailing Address - Fax:601-687-5497
Practice Address - Street 1:114 SECOND STREET
Practice Address - Street 2:
Practice Address - City:SHUBUTA
Practice Address - State:MS
Practice Address - Zip Code:39360
Practice Address - Country:US
Practice Address - Phone:601-687-1128
Practice Address - Fax:601-687-5497
Is Sole Proprietor?:Yes
Enumeration Date:2007-12-27
Last Update Date:2007-12-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes311ZA0620XNursing & Custodial Care FacilitiesCustodial Care FacilityAdult Care Home
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00770581Medicaid