Provider Demographics
NPI:1790444263
Name:PRIME CARE CLINIC OF CLINTON, LLC
Entity Type:Organization
Organization Name:PRIME CARE CLINIC OF CLINTON, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEMBER/COO
Authorized Official - Prefix:
Authorized Official - First Name:JUSTIN
Authorized Official - Middle Name:C
Authorized Official - Last Name:JACKSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:601-519-7692
Mailing Address - Street 1:PO BOX 785
Mailing Address - Street 2:
Mailing Address - City:CLINTON
Mailing Address - State:MS
Mailing Address - Zip Code:39060-0785
Mailing Address - Country:US
Mailing Address - Phone:601-519-7692
Mailing Address - Fax:
Practice Address - Street 1:709 CLINTON PKWY
Practice Address - Street 2:
Practice Address - City:CLINTON
Practice Address - State:MS
Practice Address - Zip Code:39056-5245
Practice Address - Country:US
Practice Address - Phone:601-259-9532
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-12-13
Last Update Date:2022-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult HealthGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS1578049276Medicaid