Basic Information
| Provider Information | |||||||||
| NPI: | 1154753986 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | JACKSON HAND AND UPPER EXTREMITY | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1904 LAKELAND DR | ||||||||
| Address2: | SUITE D | ||||||||
| City: | JACKSON | ||||||||
| State: | MS | ||||||||
| PostalCode: | 392165038 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6019422709 | ||||||||
| FaxNumber: | 6019449780 | ||||||||
| Practice Location | |||||||||
| Address1: | 1904 LAKELAND DR | ||||||||
| Address2: | SUITE D | ||||||||
| City: | JACKSON | ||||||||
| State: | MS | ||||||||
| PostalCode: | 392165038 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6019422709 | ||||||||
| FaxNumber: | 6019449780 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/02/2013 | ||||||||
| LastUpdateDate: | 07/08/2014 | ||||||||
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| AuthorizedOfficialLastName: | ROBERTS | ||||||||
| AuthorizedOfficialFirstName: | ROBYN | ||||||||
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| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 6019422709 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | PT | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | PT0987 | MS | N | 193200000X MULTI-SPECIALTY GROUP | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist | 225XH1200X | 45OT073 | MS | Y | 193200000X MULTI-SPECIALTY GROUP | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapist | Hand |
No ID Information.