Basic Information
| Provider Information | |||||||||
| NPI: | 1790996544 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | JACKSON | ||||||||
| FirstName: | JEREMY | ||||||||
| MiddleName: | DON | ||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2500 N STATE ST | ||||||||
| Address2: | UMMC-DEPARTMENT OF DERMATOLOGY | ||||||||
| City: | JACKSON | ||||||||
| State: | MS | ||||||||
| PostalCode: | 392164500 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6018153374 | ||||||||
| FaxNumber: | 6018156613 | ||||||||
| Practice Location | |||||||||
| Address1: | 2500 N STATE ST | ||||||||
| Address2: | DEPT. OF MEDICINE | ||||||||
| City: | JACKSON | ||||||||
| State: | MS | ||||||||
| PostalCode: | 392164500 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6019845601 | ||||||||
| FaxNumber: | 6019846665 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/24/2007 | ||||||||
| LastUpdateDate: | 10/06/2017 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | T-1892 | MS | N | Allopathic & Osteopathic Physicians | Internal Medicine | 207N00000X | 20241 | MS | Y | Allopathic & Osteopathic Physicians | Dermatology |
ID Information
| ID | Type | State | Issuer | Description | P01402453 | 01 | MS | RR MEDICARE | OTHER | 02585707 | 05 | MS | MEDICAID |