Organization
ST DOMINIC MEDICAL ASSOCIATES LLC
Active
Parent organization
ST DOMINIC JACKSON MEMORIAL HOSPITAL
Other names
St. Dominic Family Practice Associates-Jackson
Organization subpart
Yes
Provider details
NPI number
Legal business name
ST DOMINIC JACKSON MEMORIAL HOSPITAL
Authorized official
DANIELLE STUART (CREDENTIALING REPRESENTATIVE 2)
(601) 200-4880
Entity
Organization
Contact information
Practice address
890 LAKELAND DR, JACKSON, MS 39216-4644
(601) 200-3131
(601) 200-5929
Mailing address
PO BOX 23666, JACKSON, MS 39225-3666
(601) 200-3131
(601) 200-0710
Taxonomy
Speciality
Code
Description
License number
State
363LF0000X
Family Nurse Practitioner
Primary
R886071
MS
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
04838265
—
MS
Enumeration date
11/26/2014
Last updated
10/18/2021
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