Provider Demographics
NPI:1194566794
Name:HARRELL, JACKSON HAYES
Entity type:Individual
Prefix:
First Name:JACKSON
Middle Name:HAYES
Last Name:HARRELL
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:120 DISTRICT BLVD APT 553
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:MS
Mailing Address - Zip Code:39211-6396
Mailing Address - Country:US
Mailing Address - Phone:662-801-8822
Mailing Address - Fax:
Practice Address - Street 1:120 DISTRICT BLVD APT 553
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:MS
Practice Address - Zip Code:39211-6396
Practice Address - Country:US
Practice Address - Phone:662-801-8822
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-06-05
Last Update Date:2024-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program