Provider Demographics
NPI:1245527902
Name:MILLER, LAURA JACKSON (MD)
Entity type:Individual
Prefix:
First Name:LAURA
Middle Name:JACKSON
Last Name:MILLER
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:415 S 28TH AVE
Mailing Address - Street 2:
Mailing Address - City:HATTIESBURG
Mailing Address - State:MS
Mailing Address - Zip Code:39401-7246
Mailing Address - Country:US
Mailing Address - Phone:601-792-2071
Mailing Address - Fax:601-579-5240
Practice Address - Street 1:1014 ROSE ST
Practice Address - Street 2:
Practice Address - City:PRENTISS
Practice Address - State:MS
Practice Address - Zip Code:39474-5271
Practice Address - Country:US
Practice Address - Phone:601-792-2071
Practice Address - Fax:601-792-8134
Is Sole Proprietor?:No
Enumeration Date:2011-07-01
Last Update Date:2020-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS22311207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS06022391Medicaid