Provider Demographics
NPI:1821013095
Name:JACKSON, DANNY WADE (DO)
Entity Type:Individual
Prefix:DR
First Name:DANNY
Middle Name:WADE
Last Name:JACKSON
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
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
Is Sole Proprietor?:No
Enumeration Date:2006-07-12
Last Update Date:2010-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS09390207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00019909Medicaid
MS00019909Medicaid
MS080004205Medicare ID - Type UnspecifiedMC PART B