Individual
MRS. JACQUENETT JACKSON
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
F
Contact information
Practice address
114 SECOND STREET, SHUBUTA, MS 39360
(601) 687-1128
(601) 687-5497
Mailing address
PO BOX 462, SHUBUTA, MS 39360-0462
(601) 687-1128
(601) 687-5497
Taxonomy
Speciality
Code
Description
License number
State
311ZA0620X
Adult Care Home Facility
Primary
—
—
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
00770581
—
MS
Enumeration date
12/27/2007
Last updated
12/27/2007
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