Provider Demographics
NPI:1649252057
Name:MCHENRY, JACKIE E II (MD)
Entity type:Individual
Prefix:
First Name:JACKIE
Middle Name:E
Last Name:MCHENRY
Suffix:II
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1111 N CAUSEWAY BLVD
Mailing Address - Street 2:
Mailing Address - City:MANDEVILLE
Mailing Address - State:LA
Mailing Address - Zip Code:70471-3409
Mailing Address - Country:US
Mailing Address - Phone:985-773-1844
Mailing Address - Fax:985-893-8272
Practice Address - Street 1:140 BURKE CALHOUN CITY RD
Practice Address - Street 2:
Practice Address - City:CALHOUN CITY
Practice Address - State:MS
Practice Address - Zip Code:38916
Practice Address - Country:US
Practice Address - Phone:662-628-6300
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-11-20
Last Update Date:2018-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS14485207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
080185585OtherRAILROAD MEDICARE
MS00113820Medicaid
080185585OtherRAILROAD MEDICARE
F85329Medicare UPIN