Provider Demographics
NPI:1356954440
Name:JACKSON, NICHOLAS (BA)
Entity type:Individual
Prefix:
First Name:NICHOLAS
Middle Name:
Last Name:JACKSON
Suffix:
Gender:M
Credentials:BA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2500 NORTH STATE ST.
Mailing Address - Street 2:PREVENTIVE MEDICINE DEPARTMENT
Mailing Address - City:JACKSON
Mailing Address - State:MS
Mailing Address - Zip Code:39216
Mailing Address - Country:US
Mailing Address - Phone:601-815-8982
Mailing Address - Fax:
Practice Address - Street 1:2500 NORTH STATE ST.
Practice Address - Street 2:PREVENTIVE MEDICINE DEPARTMENT
Practice Address - City:JACKSON
Practice Address - State:MS
Practice Address - Zip Code:39216
Practice Address - Country:US
Practice Address - Phone:601-815-8982
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-08-28
Last Update Date:2020-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174H00000XOther Service ProvidersHealth Educator