Provider Demographics
NPI:1134671787
Name:JACKSON THYROID & ENDOCRINE CLINIC PLLC
Entity type:Organization
Organization Name:JACKSON THYROID & ENDOCRINE CLINIC PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:WOODY
Authorized Official - Last Name:SISTRUNK
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:601-949-6990
Mailing Address - Street 1:971 LAKELAND DR
Mailing Address - Street 2:SUITE 353
Mailing Address - City:JACKSON
Mailing Address - State:MS
Mailing Address - Zip Code:39216-4643
Mailing Address - Country:US
Mailing Address - Phone:601-949-6990
Mailing Address - Fax:601-949-6105
Practice Address - Street 1:971 LAKELAND DR
Practice Address - Street 2:SUITE 353
Practice Address - City:JACKSON
Practice Address - State:MS
Practice Address - Zip Code:39216-4643
Practice Address - Country:US
Practice Address - Phone:601-949-6990
Practice Address - Fax:601-949-6105
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-10-31
Last Update Date:2019-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS15819207RE0101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RE0101XAllopathic & Osteopathic PhysiciansInternal MedicineEndocrinology, Diabetes & MetabolismGroup - Single Specialty