Provider Demographics
NPI:1831473552
Name:MCDONALD, JACKIE CLANTON (NP-C)
Entity Type:Individual
Prefix:
First Name:JACKIE
Middle Name:CLANTON
Last Name:MCDONALD
Suffix:
Gender:F
Credentials:NP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:971 LAKELAND DR
Mailing Address - Street 2:STE 750
Mailing Address - City:JACKSON
Mailing Address - State:MS
Mailing Address - Zip Code:39216-4608
Mailing Address - Country:US
Mailing Address - Phone:601-200-4970
Mailing Address - Fax:601-200-5955
Practice Address - Street 1:971 LAKELAND DR
Practice Address - Street 2:SUITE 750
Practice Address - City:JACKSON
Practice Address - State:MS
Practice Address - Zip Code:39216-4643
Practice Address - Country:US
Practice Address - Phone:601-214-3397
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-09-29
Last Update Date:2017-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSR863322363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily