Provider Demographics
NPI:1740742329
Name:JACKSONBRACEY HEALTH CARE
Entity Type:Organization
Organization Name:JACKSONBRACEY HEALTH CARE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE STAFF
Authorized Official - Prefix:
Authorized Official - First Name:KRISTEN
Authorized Official - Middle Name:
Authorized Official - Last Name:LILES
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:601-937-5415
Mailing Address - Street 1:4490 HIGHWAY 80 E
Mailing Address - Street 2:
Mailing Address - City:PEARL
Mailing Address - State:MS
Mailing Address - Zip Code:39208-4213
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4490 US-80
Practice Address - Street 2:
Practice Address - City:PEARL
Practice Address - State:MS
Practice Address - Zip Code:39208
Practice Address - Country:US
Practice Address - Phone:601-383-1977
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-04-03
Last Update Date:2019-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Single Specialty