Provider Demographics
NPI:1528590460
Name:JACKSON, MATTHEW DEAN (MD)
Entity Type:Individual
Prefix:
First Name:MATTHEW
Middle Name:DEAN
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:601-261-3500
Mailing Address - Fax:601-579-5240
Practice Address - Street 1:4210 LINCOLN RD
Practice Address - Street 2:
Practice Address - City:HATTIESBURG
Practice Address - State:MS
Practice Address - Zip Code:39402-3093
Practice Address - Country:US
Practice Address - Phone:601-261-3500
Practice Address - Fax:601-579-5240
Is Sole Proprietor?:No
Enumeration Date:2017-03-30
Last Update Date:2022-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS29759208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics