Provider Demographics
NPI:1417061359
Name:JACKSON, ARNOLD J (MD)
Entity Type:Individual
Prefix:
First Name:ARNOLD
Middle Name:J
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 1:415 S 28TH AVE
Mailing Address - Street 2:
Mailing Address - City:HATTIESBURG
Mailing Address - State:MS
Mailing Address - Zip Code:39401-7246
Mailing Address - Country:US
Mailing Address - Phone:601-579-5463
Mailing Address - Fax:601-579-5240
Practice Address - Street 1:4 MEDICAL BLVD
Practice Address - Street 2:
Practice Address - City:HATTIESBURG
Practice Address - State:MS
Practice Address - Zip Code:39401-7230
Practice Address - Country:US
Practice Address - Phone:601-579-5444
Practice Address - Fax:601-579-5390
Is Sole Proprietor?:No
Enumeration Date:2006-08-18
Last Update Date:2015-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS04993207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS1558952OtherAMERICAN ADMIN GROUP
MS00014062Medicaid
LA1419907Medicaid
MS1558952OtherAMERICAN ADMIN GROUP
MS111816555Medicare PIN
D73573Medicare UPIN