Basic Information
| Provider Information | |||||||||
| NPI: | 1255992525 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | JACKSON | ||||||||
| FirstName: | KACI | ||||||||
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| OtherLastName: | THOMPSON | ||||||||
| OtherFirstName: | KACI | ||||||||
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| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 711 AVIGNON DR | ||||||||
| Address2: | |||||||||
| City: | RIDGELAND | ||||||||
| State: | MS | ||||||||
| PostalCode: | 391575120 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6016056777 | ||||||||
| FaxNumber: | 6016071362 | ||||||||
| Practice Location | |||||||||
| Address1: | 78 HOSPITAL RD | ||||||||
| Address2: | |||||||||
| City: | MACON | ||||||||
| State: | MS | ||||||||
| PostalCode: | 393412490 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6627264231 | ||||||||
| FaxNumber: | 6016071345 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/26/2019 | ||||||||
| LastUpdateDate: | 06/26/2019 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | PT5726 | MS | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
No ID Information.