Provider Demographics
NPI:1780737577
Name:JACKSON ANESTHESIA ASSOCIATES PA
Entity type:Organization
Organization Name:JACKSON ANESTHESIA ASSOCIATES PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALING
Authorized Official - Prefix:MRS
Authorized Official - First Name:JOYCE
Authorized Official - Middle Name:
Authorized Official - Last Name:MARTIN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:601-969-1171
Mailing Address - Street 1:PO BOX 22656
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:MS
Mailing Address - Zip Code:39225-2656
Mailing Address - Country:US
Mailing Address - Phone:888-502-0531
Mailing Address - Fax:601-969-6749
Practice Address - Street 1:1151 N STATE ST
Practice Address - Street 2:SUITE 311
Practice Address - City:JACKSON
Practice Address - State:MS
Practice Address - Zip Code:39202
Practice Address - Country:US
Practice Address - Phone:601-969-1171
Practice Address - Fax:601-969-6749
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-18
Last Update Date:2022-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS09013225Medicaid
MS09013225Medicaid