Provider Demographics
NPI:1417314865
Name:JACKSON NEUROSCIENCE CENTER
Entity Type:Organization
Organization Name:JACKSON NEUROSCIENCE CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MGR
Authorized Official - Prefix:
Authorized Official - First Name:RON
Authorized Official - Middle Name:
Authorized Official - Last Name:MILONE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:601-992-5943
Mailing Address - Street 1:207 W JACKSON ST
Mailing Address - Street 2:SUITE 1
Mailing Address - City:RIDGELAND
Mailing Address - State:MS
Mailing Address - Zip Code:39157-2355
Mailing Address - Country:US
Mailing Address - Phone:601-992-5943
Mailing Address - Fax:601-992-9152
Practice Address - Street 1:207 W JACKSON ST
Practice Address - Street 2:SUITE 1
Practice Address - City:RIDGELAND
Practice Address - State:MS
Practice Address - Zip Code:39157-2355
Practice Address - Country:US
Practice Address - Phone:601-992-5943
Practice Address - Fax:601-992-9152
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-01-15
Last Update Date:2016-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS16393102L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes102L00000XBehavioral Health & Social Service ProvidersPsychoanalystGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MSG50211OtherUPIN
MS00118254Medicaid
MS302I265901Medicare PIN