Doctor Name: | RANDALL JACKSON |
NPI Number: | 1144614165 |
Entity Type Code: | Individual (1) |
Gender: | M |
Credentials: | CFNP |
License Number: | R878547 |
Business Practice Address: | 215 Marion Ave Mccomb, MS - 396482705 |
Business Phone Number: | 6012495500 |
Business Fax Number: | 6012491173 |
Mailing Address: | Po Box 490, MCCOMB |
State: | MS |
Postal Code: | 396490490 |
Phone Number: | 6012492701 |
Fax Number: | 6012492195 |
NPI Enumeration Date: | 03/27/2015 |
NPI Last Update Date: | 04/22/2015 |
Replacement NPI: | 0 |
NPI Deactivation Date: | |
NPI Reactivation Date: |
Taxonomy Information: | |
Healthcare Provider Taxonomy: | 363LF0000X |
License Number: | R878547 |
Healthcare Provider Taxonomy: (Secondary) | Y |
State: | MS |
Taxonomy Type: | Physician Assistants & Advanced Practice Nursing Providers |
Taxonomy Classification: | Nurse Practitioner |
Taxonomy Specialization: | Family |
Taxonomy Definition: |