Provider Demographics
NPI:1700132545
Name:HALL, JOHN JACOBS (MD)
Entity Type:Individual
Prefix:DR
First Name:JOHN
Middle Name:JACOBS
Last Name:HALL
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Mailing Address - Street 1:2101 HIGHWAY 90
Mailing Address - Street 2:
Mailing Address - City:GAUTIER
Mailing Address - State:MS
Mailing Address - Zip Code:39553-5340
Mailing Address - Country:US
Mailing Address - Phone:228-497-7576
Mailing Address - Fax:228-497-8869
Practice Address - Street 1:15190 COMMUNITY RD STE 260
Practice Address - Street 2:
Practice Address - City:GULFPORT
Practice Address - State:MS
Practice Address - Zip Code:39503-3471
Practice Address - Country:US
Practice Address - Phone:228-762-4483
Practice Address - Fax:228-762-3147
Is Sole Proprietor?:No
Enumeration Date:2012-07-30
Last Update Date:2022-03-02
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MS25539208600000X, 208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS06084255Medicaid