Basic Information
| Provider Information | |||||||||
| NPI: | 1881606440 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | GEORGE | ||||||||
| FirstName: | JESSIE | ||||||||
| MiddleName: | ANN | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 2153 | ||||||||
| Address2: | DEPT 1947 | ||||||||
| City: | BIRMINGHAM | ||||||||
| State: | AL | ||||||||
| PostalCode: | 352870002 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6019441717 | ||||||||
| FaxNumber: | 6019449780 | ||||||||
| Practice Location | |||||||||
| Address1: | 1190 N STATE ST | ||||||||
| Address2: | SUITE 204 | ||||||||
| City: | JACKSON | ||||||||
| State: | MS | ||||||||
| PostalCode: | 392022413 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6019731624 | ||||||||
| FaxNumber: | 6019731596 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/12/2006 | ||||||||
| LastUpdateDate: | 06/09/2016 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 13439R | LA | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 1431923 | 05 | LA | MEDICAID |