Provider Demographics
NPI:1962823344
Name:JACKSON PAIN CENTER PA
Entity Type:Organization
Organization Name:JACKSON PAIN CENTER PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:EDWIN
Authorized Official - Last Name:DODD
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:601-355-7246
Mailing Address - Street 1:1151 N STATE ST
Mailing Address - Street 2:SUITE 311
Mailing Address - City:JACKSON
Mailing Address - State:MS
Mailing Address - Zip Code:39202-2407
Mailing Address - Country:US
Mailing Address - Phone:601-355-7246
Mailing Address - Fax:601-969-1173
Practice Address - Street 1:1151 N STATE ST
Practice Address - Street 2:SUITE 311
Practice Address - City:JACKSON
Practice Address - State:MS
Practice Address - Zip Code:39202-2407
Practice Address - Country:US
Practice Address - Phone:601-355-7246
Practice Address - Fax:601-969-1173
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-01-02
Last Update Date:2014-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS10764207LP2900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207LP2900XAllopathic & Osteopathic PhysiciansAnesthesiologyPain MedicineGroup - Single Specialty