Provider Demographics
NPI:1609402304
Name:JACKSON, VALERIE THRESA
Entity Type:Individual
Prefix:
First Name:VALERIE
Middle Name:THRESA
Last Name:JACKSON
Suffix:
Gender:F
Credentials:
Other - Prefix:MRS
Other - First Name:VALERIE
Other - Middle Name:THRESA
Other - Last Name:JACKSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1171 HART ST
Mailing Address - Street 2:
Mailing Address - City:CANTON
Mailing Address - State:MS
Mailing Address - Zip Code:39046-4805
Mailing Address - Country:US
Mailing Address - Phone:601-622-2428
Mailing Address - Fax:
Practice Address - Street 1:1171 HART ST
Practice Address - Street 2:
Practice Address - City:CANTON
Practice Address - State:MS
Practice Address - Zip Code:39046-4805
Practice Address - Country:US
Practice Address - Phone:601-622-2428
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-03-14
Last Update Date:2022-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSR865187163WH0500X
MS9049998363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163WH0500XNursing Service ProvidersRegistered NurseHemodialysis