Basic Information
Provider Information | |||||||||
NPI: | 1285716928 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | JACKSON VA MEDICAL CENTER | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 1500 E WOODROW WILSON AVE | ||||||||
Address2: |   | ||||||||
City: | JACKSON | ||||||||
State: | MS | ||||||||
PostalCode: | 392165116 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6013624471 | ||||||||
FaxNumber: | 6013641298 | ||||||||
Practice Location | |||||||||
Address1: | 1500 E WOODROW WILSON AVE | ||||||||
Address2: |   | ||||||||
City: | JACKSON | ||||||||
State: | MS | ||||||||
PostalCode: | 392165116 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6013624471 | ||||||||
FaxNumber: | 6013641298 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 10/20/2006 | ||||||||
LastUpdateDate: | 08/22/2020 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | BALTZ | ||||||||
AuthorizedOfficialFirstName: | RICHARD | ||||||||
AuthorizedOfficialMiddleName: | J | ||||||||
AuthorizedOfficialTitleorPosition: | CENTER DIRECTOR | ||||||||
AuthorizedOfficialTelephone: | 6013641359 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: | DR. | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: | D.O | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 324500000X |   |   | Y |   | Residential Treatment Facilities | Substance Abuse Rehabilitation Facility |   |
No ID Information.