Basic Information
| Provider Information | |||||||||
| NPI: | 1740364785 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | JACKSON NEUROSURGERY CLINIC, PLLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1080 RIVER OAKS DR | ||||||||
| Address2: | SUITE B-103 | ||||||||
| City: | FLOWOOD | ||||||||
| State: | MS | ||||||||
| PostalCode: | 392329779 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6013661011 | ||||||||
| FaxNumber: | 6019326111 | ||||||||
| Practice Location | |||||||||
| Address1: | 1080 RIVER OAKS DR | ||||||||
| Address2: | SUITE B-103 | ||||||||
| City: | FLOWOOD | ||||||||
| State: | MS | ||||||||
| PostalCode: | 392329779 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6013661011 | ||||||||
| FaxNumber: | 6019326111 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/25/2006 | ||||||||
| LastUpdateDate: | 10/28/2016 | ||||||||
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| AuthorizedOfficialLastName: | LEWIS | ||||||||
| AuthorizedOfficialFirstName: | ZOE | ||||||||
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| AuthorizedOfficialTitleorPosition: | PRACTICE ADMINISTRATOR | ||||||||
| AuthorizedOfficialTelephone: | 6013211504 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 174400000X | MS | Y | 193200000X MULTI-SPECIALTY GROUP | Other Service Providers | Specialist |
ID Information
| ID | Type | State | Issuer | Description | 08288260 | 05 | MS | MEDICAID | C03059 | 01 | MS | MEDICARE GROUP | OTHER | CK4238 | 01 | MS | RAILROAD MEDICARE | OTHER |