Active NPI
Timothy D Jackson, MD, SA-C
- Surgical Assistant
- Gulfport, MS
National Provider Identifier
1093710089
On this page
Key facts
NPPES NPI Registry- Primary specialty
- Surgical Assistant
- License
- 19-516
- Practice address
- 4500 13TH St
Gulfport, MS 39501-2515 - Phone
- (228) 304-9436
- NPI assigned
- Jun 16, 2005
- Sex
- Male
- Sole proprietor
- Yes
NPPES NPI Registry
Registry information is reported by the provider to CMS and is not verified. About this source
Specialties & licenses 2
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Orthopaedic Surgery Physician | 207X00000X | 14510 | MS | |
| Surgical Assistant | 246ZC0007X | 19-516 | Primary |
Addresses
Primary practice location
4500 13TH St
Gulfport, MS 39501-2515
Mailing address
15520 Daniel Blvd # 310
Gulfport, MS 39503-4735
Phone (228) 304-9436
Medicare participation
Medicare enrollment files- Medicare fee-for-service enrollment
- Not listed in the public Medicare enrollment file
- Eligible to order & refer
- Part B services: Yes
- Medical equipment: Yes
- Home health: Yes
- Power mobility devices: Yes
- Hospice: Yes
National Provider Directory
National Provider Directory- Medicare enrollment (NPD)
- Not enrolled
- HHS exclusion list flag
- Flagged The directory lists this NPI on an HHS exclusion list.
- Credentials
- Doctor of Medicine
Practice roles
| Organization | Specialty | Status | New patients |
|---|---|---|---|
| Surgical Services LLC | Current | Accepting new patients | |
| Stone County Hospital, Inc | Past | Accepting new patients | |
| Advanced Orthopedics, PLLC | Single Specialty | Past | Accepting new patients |
Locations
15520 Daniel Blvd
#310
Gulfport, MS 39503
4500 13th St
Gulfport, MS 39501
Phone (228) 236-3872
Organizations & group practices 3
Organizations this provider is connected to: Medicare benefit reassignments (the organization bills Medicare for this provider’s services), Care Compare group memberships and National Provider Directory roles.
-
- Exclusive Provider Organization
- Gulfport, MS
- NPI 1487353330
-
- Ambulance
- Wiggins, MS
- NPI 1003073057
NPI Registry JSON
The complete NPPES record for this NPI in the NPI Registry API format.
{
"created_epoch": "1118880000000",
"enumeration_type": "NPI-1",
"last_updated_epoch": "1768348800000",
"number": "1093710089",
"addresses": [
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "MAILING",
"address_type": "DOM",
"address_1": "15520 DANIEL BLVD # 310",
"city": "GULFPORT",
"state": "MS",
"postal_code": "395034735",
"telephone_number": "228-304-9436"
},
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "LOCATION",
"address_type": "DOM",
"address_1": "4500 13TH ST",
"city": "GULFPORT",
"state": "MS",
"postal_code": "395012515",
"telephone_number": "228-304-9436"
}
],
"practiceLocations": [],
"basic": {
"last_name": "JACKSON",
"first_name": "TIMOTHY",
"middle_name": "D",
"name_prefix": "Dr.",
"credential": "MD, SA-C",
"sole_proprietor": "YES",
"sex": "M",
"enumeration_date": "2005-06-16",
"last_updated": "2026-01-14",
"certification_date": "2026-01-14",
"status": "A"
},
"taxonomies": [
{
"code": "207X00000X",
"taxonomy_group": "",
"desc": "Orthopaedic Surgery",
"state": "MS",
"license": "14510",
"primary": false
},
{
"code": "246ZC0007X",
"taxonomy_group": "193400000X SINGLE SPECIALTY GROUP",
"desc": "Specialist/Technologist, Other, Surgical Assistant",
"state": null,
"license": "19-516",
"primary": true
}
],
"identifiers": [],
"endpoints": [],
"other_names": []
}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 Jan 14, 2026; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
- Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments; Order and Referring.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.