Provider Demographics
NPI:1184222374
Name:JACKSON DORRIS, KIMYUANA (PMHNP, AGNP-C)
Entity type:Individual
Prefix:
First Name:KIMYUANA
Middle Name:
Last Name:JACKSON DORRIS
Suffix:
Gender:F
Credentials:PMHNP, AGNP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:20 HOBO FORK RD
Mailing Address - Street 2:
Mailing Address - City:NATCHEZ
Mailing Address - State:MS
Mailing Address - Zip Code:39120-9025
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:215 KATHERINE DR STE A
Practice Address - Street 2:
Practice Address - City:FLOWOOD
Practice Address - State:MS
Practice Address - Zip Code:39232-9588
Practice Address - Country:US
Practice Address - Phone:601-665-4162
Practice Address - Fax:888-398-1151
Is Sole Proprietor?:No
Enumeration Date:2020-10-11
Last Update Date:2024-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS904207207QA0505X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207QA0505XAllopathic & Osteopathic PhysiciansFamily MedicineAdult Medicine