Provider Demographics
NPI:1407852072
Name:JACKSON, WILLIAM G (MD)
Entity Type:Individual
Prefix:DR
First Name:WILLIAM
Middle Name:G
Last Name:JACKSON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:202 ALCORN DR
Mailing Address - Street 2:
Mailing Address - City:CORINTH
Mailing Address - State:MS
Mailing Address - Zip Code:38834-9701
Mailing Address - Country:US
Mailing Address - Phone:662-287-4481
Mailing Address - Fax:662-287-4368
Practice Address - Street 1:202 ALCORN DR
Practice Address - Street 2:
Practice Address - City:CORINTH
Practice Address - State:MS
Practice Address - Zip Code:38834-9701
Practice Address - Country:US
Practice Address - Phone:662-287-4481
Practice Address - Fax:662-287-4368
Is Sole Proprietor?:Yes
Enumeration Date:2005-06-28
Last Update Date:2013-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS7322207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00016794Medicaid
C48169Medicare UPIN
MS00016794Medicaid