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Individual

LASALLE JACKSON

Active
Sole proprietor
No

Provider details

NPI number
Gender
Man

Contact information

Practice address
606 WALNUT ST, PORT GIBSON, MS 39150-2140
(601) 529-0527
Mailing address
606 WALNUT ST, PORT GIBSON, MS 39150-2140
(601) 529-0527

Taxonomy

Speciality
Code
Description
License number
State
172A00000X
Driver
Primary
MS

Other

Enumeration date
10/04/2018
Last updated
10/04/2018
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