Provider Demographics
NPI:1154753986
Name:JACKSON HAND AND UPPER EXTREMITY
Entity type:Organization
Organization Name:JACKSON HAND AND UPPER EXTREMITY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ROBYN
Authorized Official - Middle Name:
Authorized Official - Last Name:ROBERTS
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:601-942-2709
Mailing Address - Street 1:1904 LAKELAND DR
Mailing Address - Street 2:SUITE D
Mailing Address - City:JACKSON
Mailing Address - State:MS
Mailing Address - Zip Code:39216-5038
Mailing Address - Country:US
Mailing Address - Phone:601-942-2709
Mailing Address - Fax:601-944-9780
Practice Address - Street 1:1904 LAKELAND DR
Practice Address - Street 2:SUITE D
Practice Address - City:JACKSON
Practice Address - State:MS
Practice Address - Zip Code:39216-5038
Practice Address - Country:US
Practice Address - Phone:601-942-2709
Practice Address - Fax:601-944-9780
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-08-02
Last Update Date:2014-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSPT0987225100000X
MS45OT073225XH1200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225XH1200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistHandGroup - Multi-Specialty
No225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS6932800001Medicare NSC