Provider Demographics
NPI:1659070043
Name:JACKSON, CHINIKKI B
Entity Type:Individual
Prefix:MS
First Name:CHINIKKI
Middle Name:B
Last Name:JACKSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:CHINIKKI
Other - Middle Name:B
Other - Last Name:TAYLOR
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1905 MISSION 66
Mailing Address - Street 2:
Mailing Address - City:VICKSBURG
Mailing Address - State:MS
Mailing Address - Zip Code:39180-3711
Mailing Address - Country:US
Mailing Address - Phone:601-738-5820
Mailing Address - Fax:
Practice Address - Street 1:1905 MISSION 66
Practice Address - Street 2:
Practice Address - City:VICKSBURG
Practice Address - State:MS
Practice Address - Zip Code:39180-3711
Practice Address - Country:US
Practice Address - Phone:601-738-5820
Practice Address - Fax:604-738-5083
Is Sole Proprietor?:No
Enumeration Date:2023-02-24
Last Update Date:2023-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator