Provider Demographics
NPI:1508468604
Name:JACKSON, NATAESHA
Entity Type:Individual
Prefix:
First Name:NATAESHA
Middle Name:
Last Name:JACKSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:252 CHARLENE DR
Mailing Address - Street 2:
Mailing Address - City:BYRAM
Mailing Address - State:MS
Mailing Address - Zip Code:39272-6418
Mailing Address - Country:US
Mailing Address - Phone:601-405-1677
Mailing Address - Fax:
Practice Address - Street 1:252 CHARLENE DR
Practice Address - Street 2:
Practice Address - City:BYRAM
Practice Address - State:MS
Practice Address - Zip Code:39272-6418
Practice Address - Country:US
Practice Address - Phone:601-405-1677
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-11-12
Last Update Date:2020-11-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS800395307172A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172A00000XOther Service ProvidersDriver