Individual
RANDALL JACKSON
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
CFNP
Contact information
Practice address
215 MARION AVE, MCCOMB, MS 39648-2705
(601) 249-5500
(601) 249-1173
Mailing address
PO BOX 490, MCCOMB, MS 39649-0490
(601) 249-2701
(601) 249-2195
Taxonomy
Speciality
Code
Description
License number
State
363LA2100X
Acute Care Nurse Practitioner
Primary
878547
MS
363LF0000X
Family Nurse Practitioner
R878547
MS
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
05435530
—
MS
Enumeration date
03/27/2015
Last updated
05/02/2022
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