Provider Demographics
NPI:1386813806
Name:JACKSON MEDICAL SUPPLY INC
Entity Type:Organization
Organization Name:JACKSON MEDICAL SUPPLY INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:ALISA
Authorized Official - Middle Name:
Authorized Official - Last Name:TEKHONOVA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:601-923-3275
Mailing Address - Street 1:2147 HENRY HILL DR
Mailing Address - Street 2:STE 109
Mailing Address - City:JACKSON
Mailing Address - State:MS
Mailing Address - Zip Code:39204-2001
Mailing Address - Country:US
Mailing Address - Phone:601-923-3275
Mailing Address - Fax:
Practice Address - Street 1:2147 HENRY HILL DR
Practice Address - Street 2:STE 109
Practice Address - City:JACKSON
Practice Address - State:MS
Practice Address - Zip Code:39204-2001
Practice Address - Country:US
Practice Address - Phone:601-923-3275
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-02-28
Last Update Date:2008-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies