Provider Demographics
NPI:1720317688
Name:JACKSON, GARY HOWARD (MD)
Entity Type:Individual
Prefix:DR
First Name:GARY
Middle Name:HOWARD
Last Name:JACKSON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:38 BENT PEBBLE PT
Mailing Address - Street 2:
Mailing Address - City:LUMBERTON
Mailing Address - State:MS
Mailing Address - Zip Code:39455-9037
Mailing Address - Country:US
Mailing Address - Phone:601-794-8081
Mailing Address - Fax:601-794-8081
Practice Address - Street 1:38 BENT PEBBLE PT
Practice Address - Street 2:
Practice Address - City:LUMBERTON
Practice Address - State:MS
Practice Address - Zip Code:39455-9037
Practice Address - Country:US
Practice Address - Phone:601-794-8081
Practice Address - Fax:601-794-8081
Is Sole Proprietor?:Yes
Enumeration Date:2009-12-23
Last Update Date:2009-12-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS07677207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery