Provider Demographics
NPI:1740626290
Name:JACKSON, YOLANDA H
Entity type:Individual
Prefix:MRS
First Name:YOLANDA
Middle Name:H
Last Name:JACKSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:512 THOMAS ST.
Mailing Address - Street 2:
Mailing Address - City:BOYLE
Mailing Address - State:MS
Mailing Address - Zip Code:38730
Mailing Address - Country:US
Mailing Address - Phone:663-545-4867
Mailing Address - Fax:
Practice Address - Street 1:512 THOMAS ST.
Practice Address - Street 2:
Practice Address - City:BOYLE
Practice Address - State:MS
Practice Address - Zip Code:38730
Practice Address - Country:US
Practice Address - Phone:662-545-4867
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-05-10
Last Update Date:2013-05-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS251T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251T00000XAgenciesProgram of All-Inclusive Care for the Elderly (PACE) Provider Organization
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS38730Medicaid