Provider Demographics
NPI:1295581486
Name:JACKSON, AMANDA DEGNAN
Entity type:Individual
Prefix:
First Name:AMANDA
Middle Name:DEGNAN
Last Name:JACKSON
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5699 GETWELL RD STE 5
Mailing Address - Street 2:
Mailing Address - City:SOUTHAVEN
Mailing Address - State:MS
Mailing Address - Zip Code:38672-7312
Mailing Address - Country:US
Mailing Address - Phone:662-205-0098
Mailing Address - Fax:662-272-1583
Practice Address - Street 1:5699 GETWELL RD STE 5
Practice Address - Street 2:
Practice Address - City:SOUTHAVEN
Practice Address - State:MS
Practice Address - Zip Code:38672-7312
Practice Address - Country:US
Practice Address - Phone:901-297-9122
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-04-29
Last Update Date:2025-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS906654363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental HealthGroup - Single Specialty