Jacquenett Jackson

Primary specialty

Adult Care Home FacilityTaxonomy code 311ZA0620X

Practice address

114 Second Street
Shubuta, MS 39360

Phone

(601) 687-1128

Fax

(601) 687-5497

NPI assigned

Dec 27, 2007

Last updated

Dec 27, 2007By the provider in NPPES

Sex

Female

Sole proprietor

Yes

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

Specialties & licenses 1

Addresses

Other identifiers 1

Other names 1

• Annette Smith Other name

Medicare fee-for-service enrollment

Not listed in the public Medicare enrollment file

Medicare enrollment (NPD)

Not enrolled

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

{
    "created_epoch": "1198713600000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1198713600000",
    "number": "1376727388",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "PO BOX 462",
            "city": "SHUBUTA",
            "state": "MS",
            "postal_code": "393600462",
            "telephone_number": "601-687-1128",
            "fax_number": "601-687-5497"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "114 SECOND STREET",
            "city": "SHUBUTA",
            "state": "MS",
            "postal_code": "39360",
            "telephone_number": "601-687-1128",
            "fax_number": "601-687-5497"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "last_name": "JACKSON",
        "first_name": "JACQUENETT",
        "name_prefix": "Mrs.",
        "sole_proprietor": "YES",
        "sex": "F",
        "enumeration_date": "2007-12-27",
        "last_updated": "2007-12-27",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "311ZA0620X",
            "taxonomy_group": "",
            "desc": "Custodial Care Facility, Adult Care Home",
            "state": "NU",
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "00770581",
            "state": "MS"
        }
    ],
    "endpoints": [],
    "other_names": [
        {
            "first_name": "ANNETTE",
            "last_name": "SMITH",
            "code": "5",
            "type": "Other Name"
        }
    ]
}

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• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Dec 27, 2007; 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.