Basic Information
| Provider Information | |||||||||
| NPI: | 1982702155 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | THOMAS | ||||||||
| FirstName: | JACKSON | ||||||||
| MiddleName: | SCOTT | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 321406 | ||||||||
| Address2: | |||||||||
| City: | FLOWOOD | ||||||||
| State: | MS | ||||||||
| PostalCode: | 392321406 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6018359270 | ||||||||
| FaxNumber: | 6018335210 | ||||||||
| Practice Location | |||||||||
| Address1: | 427 HIGHWAY 51 N | ||||||||
| Address2: | |||||||||
| City: | BROOKHAVEN | ||||||||
| State: | MS | ||||||||
| PostalCode: | 396012350 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6018359270 | ||||||||
| FaxNumber: | 6018335210 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/20/2006 | ||||||||
| LastUpdateDate: | 07/09/2007 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | 15444 | MS | Y | Allopathic & Osteopathic Physicians | Pediatrics |
ID Information
| ID | Type | State | Issuer | Description | MS15444 | 01 | MS | MS LICENSE NUMBER | OTHER | 00119589 | 05 | MS | MEDICAID |