Individual
JIMMY R JACKSON
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
CRNA
Contact information
Practice address
830 SOUTH GLOSTER, TUPELO, MS 38801
(662) 377-4394
(662) 377-7045
Mailing address
PO BOX 3294, TUPELO, MS 38803-3294
(662) 377-4394
(662) 377-7045
Taxonomy
Speciality
Code
Description
License number
State
367500000X
Certified Registered Nurse Anesthetist
Primary
R539929
MS
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
00110004
—
MS
05
—
009936743
—
AL
Enumeration date
07/17/2006
Last updated
11/09/2010
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