Provider Demographics
NPI:1992870950
Name:JACKSON BRACE AND LIMB COMPANY
Entity type:Organization
Organization Name:JACKSON BRACE AND LIMB COMPANY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SECRETARY TREASURER
Authorized Official - Prefix:MRS
Authorized Official - First Name:DELESE
Authorized Official - Middle Name:
Authorized Official - Last Name:GORDON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:601-353-2477
Mailing Address - Street 1:1320 N STATE ST
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:MS
Mailing Address - Zip Code:39202-2003
Mailing Address - Country:US
Mailing Address - Phone:601-353-2477
Mailing Address - Fax:601-355-4100
Practice Address - Street 1:1320 N STATE ST
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:MS
Practice Address - Zip Code:39202-2003
Practice Address - Country:US
Practice Address - Phone:601-353-2477
Practice Address - Fax:601-355-4100
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-22
Last Update Date:2008-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes335E00000XSuppliersProsthetic/Orthotic Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00040095Medicaid
MS000012226OtherBLUE CROSS BLUE SHIELD
0335500001Medicare NSC