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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