Provider Demographics
NPI:1154549707
Name:CENTRAL JACKSON FAMILY MEDICAL CLINIC
Entity type:Organization
Organization Name:CENTRAL JACKSON FAMILY MEDICAL CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICAIN
Authorized Official - Prefix:DR
Authorized Official - First Name:CASSANDRA
Authorized Official - Middle Name:FAYE
Authorized Official - Last Name:THOMAS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:601-981-7198
Mailing Address - Street 1:P.O. BOX 4610
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:MS
Mailing Address - Zip Code:39296-4610
Mailing Address - Country:US
Mailing Address - Phone:601-981-7198
Mailing Address - Fax:601-981-6616
Practice Address - Street 1:514 C WOODROW WILSON
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:MS
Practice Address - Zip Code:39216
Practice Address - Country:US
Practice Address - Phone:601-981-7198
Practice Address - Fax:601-981-6616
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-20
Last Update Date:2010-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS13653261QM2500X
MS18905261QM2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM2500XAmbulatory Health Care FacilitiesClinic/CenterMedical Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00937242Medicaid
MS00112137Medicaid
MS00937242Medicaid
MSI37668Medicare UPIN
MS080004177Medicare ID - Type Unspecified
MS00112137Medicaid