Provider Demographics
NPI:1831147917
Name:JEFFERSON, JAMES ANDREW (MD)
Entity type:Individual
Prefix:DR
First Name:JAMES
Middle Name:ANDREW
Last Name:JEFFERSON
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:PO BOX 588
Mailing Address - Street 2:
Mailing Address - City:CANTON
Mailing Address - State:MS
Mailing Address - Zip Code:39046-0588
Mailing Address - Country:US
Mailing Address - Phone:601-859-5213
Mailing Address - Fax:601-859-8771
Practice Address - Street 1:1668 W PEACE ST
Practice Address - Street 2:
Practice Address - City:CANTON
Practice Address - State:MS
Practice Address - Zip Code:39046-5332
Practice Address - Country:US
Practice Address - Phone:601-859-5213
Practice Address - Fax:601-859-8771
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-04
Last Update Date:2014-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS11737207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MSC67669Medicare UPIN