Provider Demographics
NPI:1972696516
Name:JACKSON, LISA THOMPSON (CRNA)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:THOMPSON
Last Name:JACKSON
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:503 GLEN GLADE
Mailing Address - Street 2:
Mailing Address - City:BRANDON
Mailing Address - State:MS
Mailing Address - Zip Code:39047
Mailing Address - Country:US
Mailing Address - Phone:601-919-8719
Mailing Address - Fax:
Practice Address - Street 1:1500 E. WOODROW WILSON
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:MS
Practice Address - Zip Code:39216
Practice Address - Country:US
Practice Address - Phone:601-362-4471
Practice Address - Fax:601-368-4479
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-02
Last Update Date:2011-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSR545228367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS302I438568Medicare PIN