Provider Demographics
NPI:1659556298
Name:JACKSON PEDIATRIC ASSOCIATES P A
Entity Type:Organization
Organization Name:JACKSON PEDIATRIC ASSOCIATES P A
Other - Org Name:CHADWICK DRIVE CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:YOLANDA
Authorized Official - Middle Name:W
Authorized Official - Last Name:WILSON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:601-707-5381
Mailing Address - Street 1:297 HIGHWAY 51 STE B
Mailing Address - Street 2:
Mailing Address - City:RIDGELAND
Mailing Address - State:MS
Mailing Address - Zip Code:39157-3423
Mailing Address - Country:US
Mailing Address - Phone:601-707-5381
Mailing Address - Fax:601-737-5382
Practice Address - Street 1:1824 HOSPITAL DR
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:MS
Practice Address - Zip Code:39204-3410
Practice Address - Country:US
Practice Address - Phone:601-346-4586
Practice Address - Fax:601-346-4587
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:JACKSON PEDIATRIC ASSOCIATES
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2008-01-02
Last Update Date:2011-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS12555174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS07325898Medicaid