Provider Demographics
NPI:1659304301
Name:DR. DANNY W JACKSON D.O. PA
Entity Type:Organization
Organization Name:DR. DANNY W JACKSON D.O. PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:DANNY
Authorized Official - Middle Name:
Authorized Official - Last Name:JACKSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:662-873-4361
Mailing Address - Street 1:PO BOX 520
Mailing Address - Street 2:
Mailing Address - City:ROLLING FORK
Mailing Address - State:MS
Mailing Address - Zip Code:39159-0520
Mailing Address - Country:US
Mailing Address - Phone:662-873-4361
Mailing Address - Fax:662-873-2921
Practice Address - Street 1:29 S FOURTH ST
Practice Address - Street 2:
Practice Address - City:ROLLING FORK
Practice Address - State:MS
Practice Address - Zip Code:39159-5146
Practice Address - Country:US
Practice Address - Phone:662-873-4361
Practice Address - Fax:662-873-2921
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-08
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS291U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00116560Medicaid
MSC03438Medicare ID - Type UnspecifiedMEDICARE PART B GROUP #