Organization
MORIAH
Active
Other names
Dr. Tim Jackson
Organization subpart
No
Provider details
NPI number
Authorized official
DR. TIMOTHY D JACKSON M.D. (OWNER)
(228) 832-9933
Entity
Organization
Contact information
Practice address
12080 NEW ORLEANS AVE N, GULFPORT, MS 39503-3180
(228) 832-9933
(228) 832-9916
Mailing address
PO BOX 10049, GULFPORT, MS 39505-0049
(228) 832-9933
(228) 832-9916
Taxonomy
Speciality
Code
Description
License number
State
174400000X
Specialist
Primary
14510
MS
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
00124986
—
MS
Enumeration date
02/13/2007
Last updated
08/22/2008
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