Provider Demographics
NPI:1285967943
Name:CENTRAL JACKSON MEDICAL CLINIC, INC
Entity type:Organization
Organization Name:CENTRAL JACKSON MEDICAL CLINIC, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MRS
Authorized Official - First Name:IPHOGENIER
Authorized Official - Middle Name:
Authorized Official - Last Name:BARRY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:601-981-7198
Mailing Address - Street 1:514 C E WOODROW WILSON
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:MS
Mailing Address - Zip Code:39216-4538
Mailing Address - Country:US
Mailing Address - Phone:601-981-7198
Mailing Address - Fax:601-981-6616
Practice Address - Street 1:514 C E WOODROW WILSON
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:MS
Practice Address - Zip Code:39216-4538
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:2009-09-14
Last Update Date:2009-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSR733308363LF0000X
MSR718637363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Single Specialty