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Organization
JACKSON STATE UNIVERSITY
Active
Organization
JACKSON STATE UNIVERSITY
Active
Other names
Jackson State University Sports Medicine
Organization subpart
No
Provider details
NPI number
Authorized official
MOUZON BASS III (AGENT)
(972) 367-4845
Entity
Organization
Contact information
Practice address
1400 JR LYNCH ST, JACKSON, MS 39217-0002
(601) 979-2291
Mailing address
5050 SPRING VALLEY RD, DALLAS, TX 75244-3995
Taxonomy
Speciality
Code
Description
License number
State
208D00000X
General Practice Physician
Primary
09707
MS
Other
Enumeration date
09/29/2016
Last updated
09/29/2016
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