Provider Demographics
NPI:1285716928
Name:JACKSON VA MEDICAL CENTER
Entity type:Organization
Organization Name:JACKSON VA MEDICAL CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CENTER DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:RICHARD
Authorized Official - Middle Name:J
Authorized Official - Last Name:BALTZ
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:601-364-1359
Mailing Address - Street 1:1500 E WOODROW WILSON AVE
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:MS
Mailing Address - Zip Code:39216-5116
Mailing Address - Country:US
Mailing Address - Phone:601-362-4471
Mailing Address - Fax:601-364-1298
Practice Address - Street 1:1500 E WOODROW WILSON AVE
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:MS
Practice Address - Zip Code:39216-5116
Practice Address - Country:US
Practice Address - Phone:601-362-4471
Practice Address - Fax:601-364-1298
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-20
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes324500000XResidential Treatment FacilitiesSubstance Abuse Rehabilitation Facility