Provider Demographics
NPI:1922074806
Name:JACKSON, JOSEPH (DO)
Entity Type:Individual
Prefix:
First Name:JOSEPH
Middle Name:
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 1:119 ROBERTSON ST
Mailing Address - Street 2:
Mailing Address - City:OKOLONA
Mailing Address - State:MS
Mailing Address - Zip Code:38860-1620
Mailing Address - Country:US
Mailing Address - Phone:662-447-3882
Mailing Address - Fax:662-447-2265
Practice Address - Street 1:119 ROBERTSON ST
Practice Address - Street 2:
Practice Address - City:OKOLONA
Practice Address - State:MS
Practice Address - Zip Code:38860-1620
Practice Address - Country:US
Practice Address - Phone:662-447-3882
Practice Address - Fax:662-447-2265
Is Sole Proprietor?:No
Enumeration Date:2006-02-28
Last Update Date:2011-03-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS17430207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS01371061Medicaid
MS01371061Medicaid