Provider Demographics
NPI:1841601556
Name:JACKSON, JAMES BRIAN (DMD)
Entity Type:Individual
Prefix:DR
First Name:JAMES
Middle Name:BRIAN
Last Name:JACKSON
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:811 S 28TH AVE
Mailing Address - Street 2:
Mailing Address - City:HATTIESBURG
Mailing Address - State:MS
Mailing Address - Zip Code:39402-2602
Mailing Address - Country:US
Mailing Address - Phone:601-261-2611
Mailing Address - Fax:601-984-4949
Practice Address - Street 1:811 S 28TH AVE
Practice Address - Street 2:
Practice Address - City:HATTIESBURG
Practice Address - State:MS
Practice Address - Zip Code:39402-2602
Practice Address - Country:US
Practice Address - Phone:601-261-2611
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-05-15
Last Update Date:2021-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS3742-14122300000X, 1223G0001X, 1223S0112X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
No122300000XDental ProvidersDentist
No1223G0001XDental ProvidersDentistGeneral Practice
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program