Provider Demographics
NPI:1336162718
Name:WILLIAM G. JACKSON, M.D.,P.A.
Entity Type:Organization
Organization Name:WILLIAM G. JACKSON, M.D.,P.A.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PHYSICIAN
Authorized Official - Prefix:
Authorized Official - First Name:WILLIAM
Authorized Official - Middle Name:
Authorized Official - Last Name:JACKSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:662-287-4481
Mailing Address - Street 1:202 ALCORN DR
Mailing Address - Street 2:
Mailing Address - City:CORINTH
Mailing Address - State:MS
Mailing Address - Zip Code:38834-9701
Mailing Address - Country:US
Mailing Address - Phone:662-287-4481
Mailing Address - Fax:662-287-4368
Practice Address - Street 1:202 ALCORN DR
Practice Address - Street 2:
Practice Address - City:CORINTH
Practice Address - State:MS
Practice Address - Zip Code:38834-9701
Practice Address - Country:US
Practice Address - Phone:662-287-4481
Practice Address - Fax:662-287-4368
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-26
Last Update Date:2010-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS07322207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS04339516Medicaid
MSC02843Medicare ID - Type Unspecified