Provider Demographics
NPI:1639391311
Name:JACKSON, LANA LIANE (MD)
Entity Type:Individual
Prefix:DR
First Name:LANA
Middle Name:LIANE
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 1:2500 N STATE ST
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:MS
Mailing Address - Zip Code:39216-4500
Mailing Address - Country:US
Mailing Address - Phone:601-815-3781
Mailing Address - Fax:601-984-5085
Practice Address - Street 1:2500 N STATE ST
Practice Address - Street 2:DEPT OF OTOLARYNGOLOGY
Practice Address - City:JACKSON
Practice Address - State:MS
Practice Address - Zip Code:39216-4500
Practice Address - Country:US
Practice Address - Phone:601-815-3781
Practice Address - Fax:601-984-5085
Is Sole Proprietor?:No
Enumeration Date:2007-05-03
Last Update Date:2016-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA056101207Y00000X
MS22626207Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS08350002Medicaid
AL170144Medicaid
AL170144Medicaid
MS297418YJ5DMedicare PIN