Provider Demographics
NPI:1396770749
Name:JACKSON-WILLIAMS, LORETTA (MD)
Entity type:Individual
Prefix:DR
First Name:LORETTA
Middle Name:
Last Name:JACKSON-WILLIAMS
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 1:2500 N STATE ST
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:MS
Mailing Address - Zip Code:39216-4500
Mailing Address - Country:US
Mailing Address - Phone:601-984-2538
Mailing Address - Fax:601-815-1854
Practice Address - Street 1:2500 N STATE ST
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:MS
Practice Address - Zip Code:39216-4500
Practice Address - Country:US
Practice Address - Phone:601-984-2538
Practice Address - Fax:601-815-1854
Is Sole Proprietor?:No
Enumeration Date:2006-07-12
Last Update Date:2015-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS16332207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS000019149Medicaid
MS512G700003OtherMS MEDICARE - GROUP
MSP00613193OtherMEDICARE RR#
MS930088703OtherRAILROAD MEDICARE
MS302I938850Medicare PIN
MS512G700003OtherMS MEDICARE - GROUP
MSP00613193OtherMEDICARE RR#
MSG64434Medicare UPIN
MS512I930032Medicare PIN