Provider Demographics
NPI:1659318558
Name:JACKSON HEART CLINIC. P.A.
Entity Type:Organization
Organization Name:JACKSON HEART CLINIC. P.A.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MS
Authorized Official - First Name:STEPHANIE
Authorized Official - Middle Name:S
Authorized Official - Last Name:EGGER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:601-982-7850
Mailing Address - Street 1:970 LAKELAND DR
Mailing Address - Street 2:SUITE 61
Mailing Address - City:JACKSON
Mailing Address - State:MS
Mailing Address - Zip Code:39216-4640
Mailing Address - Country:US
Mailing Address - Phone:601-982-7850
Mailing Address - Fax:601-326-6278
Practice Address - Street 1:970 LAKELAND DR
Practice Address - Street 2:SUITE 61
Practice Address - City:JACKSON
Practice Address - State:MS
Practice Address - Zip Code:39216-4640
Practice Address - Country:US
Practice Address - Phone:601-982-7850
Practice Address - Fax:601-326-6278
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-31
Last Update Date:2014-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular DiseaseGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS09011314Medicaid
MS09011314Medicaid