Basic Information
| Provider Information | |||||||||
| NPI: | 1134523830 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | WILBANKS | ||||||||
| FirstName: | RACHAEL | ||||||||
| MiddleName: | J | ||||||||
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| Credential: | NPC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 23666 | ||||||||
| Address2: | |||||||||
| City: | JACKSON | ||||||||
| State: | MS | ||||||||
| PostalCode: | 392253666 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6012005900 | ||||||||
| FaxNumber: | 6012000204 | ||||||||
| Practice Location | |||||||||
| Address1: | 969 LAKELAND DRIVE | ||||||||
| Address2: | ST. DOMINIC PALLIATIVE CARE | ||||||||
| City: | JACKSON | ||||||||
| State: | MS | ||||||||
| PostalCode: | 39216 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6012005900 | ||||||||
| FaxNumber: | 6012000204 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/09/2014 | ||||||||
| LastUpdateDate: | 11/23/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 11/10/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363L00000X | 884972 | MS | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | 363L00000X | F0814571 | MS | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |
ID Information
| ID | Type | State | Issuer | Description | 1V8513 | 01 | MS | MEDICARE (ST DOM) | OTHER | 02505821 | 05 | MS | MEDICAID |