Provider Demographics
NPI:1780713966
Name:JACKSON ONCOLOGY ASSOCIATES, PLLC
Entity type:Organization
Organization Name:JACKSON ONCOLOGY ASSOCIATES, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:RICHARD
Authorized Official - Middle Name:W
Authorized Official - Last Name:GRIFFITH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:601-974-5578
Mailing Address - Street 1:1227 N STATE ST STE 101
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:MS
Mailing Address - Zip Code:39202-2002
Mailing Address - Country:US
Mailing Address - Phone:601-355-2485
Mailing Address - Fax:601-353-1463
Practice Address - Street 1:1860 CHADWICK DR STE 301
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:MS
Practice Address - Zip Code:39204-3467
Practice Address - Country:US
Practice Address - Phone:601-373-4421
Practice Address - Fax:601-372-9227
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:JACKSON ONCOLOGY ASSOCIATES, PLLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-03-05
Last Update Date:2017-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RH0003XAllopathic & Osteopathic PhysiciansInternal MedicineHematology & OncologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS03330910Medicaid
MS03330910Medicaid
MS0639880001Medicare NSC