Provider Demographics
NPI:1457484594
Name:JACKSON PEDIATRIC ASSOCIATES
Entity Type:Organization
Organization Name:JACKSON PEDIATRIC ASSOCIATES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT CEO
Authorized Official - Prefix:
Authorized Official - First Name:YOLANDA
Authorized Official - Middle Name:W
Authorized Official - Last Name:WILSON
Authorized Official - Suffix:
Authorized Official - Credentials:M D
Authorized Official - Phone:601-707-5381
Mailing Address - Street 1:297 HIGHWAY 51 STE B
Mailing Address - Street 2:
Mailing Address - City:RIDGELAND
Mailing Address - State:MS
Mailing Address - Zip Code:39157-3423
Mailing Address - Country:US
Mailing Address - Phone:601-707-5381
Mailing Address - Fax:601-707-5382
Practice Address - Street 1:297 HIGHWAY 51 STE B
Practice Address - Street 2:
Practice Address - City:RIDGELAND
Practice Address - State:MS
Practice Address - Zip Code:39157-3423
Practice Address - Country:US
Practice Address - Phone:601-707-5381
Practice Address - Fax:601-707-5382
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-14
Last Update Date:2011-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS12555174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS09015867Medicaid