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Specialty details in registry · Jackson, MS

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At a glance

5773 Old Canton Rd, Jackson, MS 39211-3202

NPPES record updated Aug 31, 2020. Public records can lag behind changes at a practice.

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  • Are you accepting new patients?
  • Do you accept my specific insurance plan?
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Insurance participation and appointment availability are not established by these public records.

Practice location

5773 Old Canton Rd
Jackson, MS 39211-3202
Professional details: NPI, taxonomy & registry record
NPI1790331643
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Registry details

Primary taxonomy
Specialty details in registry
Taxonomy code
2083P0901X
Enumeration date
Aug 16, 2019
Record updated
Aug 31, 2020
More registry details
Provider type
Organization · Type 2

Reported taxonomies and licenses

Specialty details in registry

172V00000X

Specialty details in registry

174H00000X

Specialty details in registry

2083P0901X · Primary

Specialty details in registry

224Y00000X

License numbers and credentials are reported to NPPES; HCPList does not independently verify them.

Practice location

5773 Old Canton Rd
Jackson, MS 39211-3202
Phone
(601) 456-9894
Mailing address
5773 OLD CANTON RD

JACKSON, MS 392113202
Source: NPPES Source through Oct 18, 2026An NPI does not verify licensure or credentials.

Information may be outdated or incomplete. Confirm details directly with the practice. HCPList is an independent directory and is not affiliated with CMS.

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