Provider Demographics
NPI:1477663318
Name:JACKSON, DENA W (MD)
Entity Type:Individual
Prefix:
First Name:DENA
Middle Name:W
Last Name:JACKSON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:940 BROOKWAY BLVD
Mailing Address - Street 2:
Mailing Address - City:BROOKHAVEN
Mailing Address - State:MS
Mailing Address - Zip Code:39601-2644
Mailing Address - Country:US
Mailing Address - Phone:601-823-5000
Mailing Address - Fax:601-823-4140
Practice Address - Street 1:940 BROOKWAY BLVD
Practice Address - Street 2:
Practice Address - City:BROOKHAVEN
Practice Address - State:MS
Practice Address - Zip Code:39601-2644
Practice Address - Country:US
Practice Address - Phone:601-823-5000
Practice Address - Fax:601-823-4140
Is Sole Proprietor?:No
Enumeration Date:2006-08-30
Last Update Date:2016-11-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS15989207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00124165Medicaid
MSP01402452OtherRR MEDICARE
MSP00918512Medicare PIN
MS432924YJ9XMedicare PIN
MS00124165Medicaid
MS302I115868Medicare PIN