Basic Information
| Provider Information | |||||||||
| NPI: | 1831360510 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | JACKSON BONE AND JOINT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1600 N STATE ST | ||||||||
| Address2: | STE 400 | ||||||||
| City: | JACKSON | ||||||||
| State: | MS | ||||||||
| PostalCode: | 392021689 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6019441717 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1225 N STATE ST | ||||||||
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| City: | JACKSON | ||||||||
| State: | MS | ||||||||
| PostalCode: | 392022064 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6019681000 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 03/20/2008 | ||||||||
| LastUpdateDate: | 03/20/2008 | ||||||||
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| AuthorizedOfficialLastName: | GRISSETT | ||||||||
| AuthorizedOfficialFirstName: | AMY | ||||||||
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| AuthorizedOfficialTitleorPosition: | ADMINISTRATOR | ||||||||
| AuthorizedOfficialTelephone: | 6019441717 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207X00000X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Orthopaedic Surgery |
ID Information
| ID | Type | State | Issuer | Description | 00116141 | 05 | MS | MEDICAID | 09015408 | 05 | MS | MEDICAID |