NPIMap

Organization Active NPI

Moriah

Doing business as Dr. Tim Jackson

  • Specialist
  • Gulfport, MS
National Provider Identifier
1003958117
Registry record updated Aug 22, 2008
On this page

Key facts

NPPES NPI Registry
Primary specialty
SpecialistTaxonomy code 174400000X
License
14510 Issued in MS
Legal business name
MORIAH
Doing business as
Dr. Tim Jackson
Practice address
12080 New Orleans Ave N
Gulfport, MS 39503-3180
Phone
(228) 832-9933
Fax
(228) 832-9916
NPI assigned
Feb 13, 2007
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Aug 22, 2008

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name
Dr. Timothy D Jackson, M.D.
Title
Owner
Phone
(228) 832-9933

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
SpecialistGroup: 193400000X SINGLE SPECIALTY GROUP 174400000X 14510 MS Primary

Addresses

Primary practice location

12080 New Orleans Ave N
Gulfport, MS 39503-3180

Mailing address

PO Box 10049
Gulfport, MS 39505-0049
Phone (228) 832-9933

Other identifiers 1

IdentifierTypeStateIssuer
00124986MedicaidMS

Other names 1

  • Dr. Tim Jackson Doing business as

National Provider Directory

National Provider Directory

Locations

12080 New Orleans Ave N
Gulfport, MS 39503
Phone (228) 832-9933

Practitioners & affiliated clinicians

Practitioners 3

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles.

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1171324800000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1219363200000",
    "number": "1003958117",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "PO BOX 10049",
            "city": "GULFPORT",
            "state": "MS",
            "postal_code": "395050049",
            "telephone_number": "228-832-9933",
            "fax_number": "228-832-9916"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "12080 NEW ORLEANS AVE N",
            "city": "GULFPORT",
            "state": "MS",
            "postal_code": "395033180",
            "telephone_number": "228-832-9933",
            "fax_number": "228-832-9916"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "MORIAH",
        "organizational_subpart": "NO",
        "enumeration_date": "2007-02-13",
        "last_updated": "2008-08-22",
        "status": "A",
        "authorized_official_last_name": "JACKSON",
        "authorized_official_first_name": "TIMOTHY",
        "authorized_official_middle_name": "D",
        "authorized_official_title_or_position": "OWNER",
        "authorized_official_telephone_number": "228-832-9933",
        "authorized_official_name_prefix": "Dr.",
        "authorized_official_credential": "M.D."
    },
    "taxonomies": [
        {
            "code": "174400000X",
            "taxonomy_group": "193400000X SINGLE SPECIALTY  GROUP",
            "desc": "Specialist",
            "state": "MS",
            "license": "14510",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "00124986",
            "state": "MS"
        }
    ],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "Dr. Tim Jackson",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

Other providers in Gulfport, MS

Sources for this page

  • NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Aug 22, 2008; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
  • National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.