NPIMap

Organization Active NPI

St Dominic Medical Associates LLC

Doing business as St. Dominic Family Practice Associates-Jackson

  • Family Nurse Practitioner
  • Jackson, MS
National Provider Identifier
1508263179
Registry record updated Oct 18, 2021
On this page

Key facts

NPPES NPI Registry
Primary specialty
Family Nurse PractitionerTaxonomy code 363LF0000X
License
R886071 Issued in MS
Legal business name
ST DOMINIC MEDICAL ASSOCIATES LLC
Doing business as
St. Dominic Family Practice Associates-Jackson
Practice address
890 Lakeland Dr
Jackson, MS 39216-4644
Phone
(601) 200-3131
Fax
(601) 200-5929
NPI assigned
Nov 26, 2014
Last updated
Oct 18, 2021By the provider in NPPES
Organization subpart
Yes
Parent organization
ST DOMINIC JACKSON MEMORIAL HOSPITALAs reported in NPPES

NPPES NPI Registry

Updated by the provider on Oct 18, 2021

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

Authorized official

Name
Danielle Stuart
Title
Credentialing Representative 2
Phone
(601) 200-4880

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
Family Nurse PractitionerGroup: 193200000X MULTI-SPECIALTY GROUP 363LF0000X R886071 MS Primary

Addresses

Primary practice location

890 Lakeland Dr
Jackson, MS 39216-4644

Mailing address

PO Box 23666
Jackson, MS 39225-3666
Phone (601) 200-3131

Other practice location 1

5005 Old Canton Rd
Jackson, MS 39211-5421
Phone (601) 200-3131

Other practice location 2

2050 Treetops Blvd Ste 140
Flowood, MS 39232-7612
Phone (601) 200-3131

Other identifiers 1

IdentifierTypeStateIssuer
04838265MedicaidMS

Other names 1

  • St. Dominic Family Practice Associates-Jackson Doing business as

National Provider Directory

National Provider Directory
Tax ID family
St Dominic Medical Associates LLC28 organizations share this tax ID, including this one
Part of
St Dominic-Jackson Memorial Hospital

Other organizations with this tax ID 27

Organizations that report the same tax identification number in the National Provider Directory.

View all 27

Locations

1297 W Government St
Brandon, MS 39042
Phone (601) 200-4790

728 Clinton Pkwy
#B
Clinton, MS 39056
Phone (601) 200-4800

736 Clinton Pkwy
Clinton, MS 39056
Phone (601) 488-4086

205 Belle Meade Pt
Flowood, MS 39232

205 Belle Meade Pt
#A
Flowood, MS 39232

1123 Highway 35 N
Forest, MS 39074

286 Calhoun Station Pkwy
Gluckstadt, MS 39110
Phone (601) 200-4321

110 E Baker St
Indianola, MS 38751
Phone (662) 887-5155

1020 River Oaks Dr
Ste 420
Jackson, MS 39232
Phone (601) 939-0361

3800 I 55 Frontage Rd N
#102
Jackson, MS 39211

3800 I 55 N
Jackson, MS 39211
Phone (601) 200-3104

3800 I 55 N
Ste 102
Jackson, MS 39211
Phone (601) 200-6872

969 Lakeland Dr
#6
Jackson, MS 39216

969 Lakeland Dr
Ste 109
Jackson, MS 39216

969 Lakeland Dr
Ste 1453
Jackson, MS 39216

970 Lakeland Dr
Ste 657
Jackson, MS 39216

971 Lakeland Dr
Jackson, MS 39216
Phone (601) 939-5922

971 Lakeland Dr
Ste 1453
Jackson, MS 39216
Phone (601) 200-5955

971 Lakeland Dr
Ste 220
Jackson, MS 39216
Phone (601) 200-2780

106 Highland Way
Ste 203
Madison, MS 39110
Phone (601) 200-3376

106 Highland Way
Ste 208
Madison, MS 39110
Phone (601) 200-3376

106 Highland Way
Ste 300
Madison, MS 39110

360 Simpson Highway 149
Ste 370
Magee, MS 39111
Phone (601) 849-1530

Practitioners & affiliated clinicians

Practitioners 129

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles, and the practitioner matching its NPPES authorized official.

View all 129

NPI Registry JSON

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

{
    "created_epoch": "1416960000000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1634515200000",
    "number": "1508263179",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "PO BOX 23666",
            "city": "JACKSON",
            "state": "MS",
            "postal_code": "392253666",
            "telephone_number": "601-200-3131",
            "fax_number": "601-200-0710"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "890 LAKELAND DR",
            "city": "JACKSON",
            "state": "MS",
            "postal_code": "392164644",
            "telephone_number": "601-200-3131",
            "fax_number": "601-200-5929"
        }
    ],
    "practiceLocations": [
        {
            "address_1": "5005 Old Canton Rd",
            "address_purpose": "LOCATION",
            "city": "Jackson",
            "state": "MS",
            "postal_code": "392115421",
            "country_code": "US",
            "telephone_number": "601-200-3131",
            "fax_number": "601-200-3109",
            "country_name": "United States",
            "address_type": "DOM"
        },
        {
            "address_1": "2050 Treetops Blvd Ste 140",
            "address_purpose": "LOCATION",
            "city": "Flowood",
            "state": "MS",
            "postal_code": "392327612",
            "country_code": "US",
            "telephone_number": "601-200-3131",
            "fax_number": "601-200-3109",
            "country_name": "United States",
            "address_type": "DOM"
        }
    ],
    "basic": {
        "organization_name": "ST DOMINIC MEDICAL ASSOCIATES LLC",
        "organizational_subpart": "YES",
        "parent_organization_legal_business_name": "ST DOMINIC JACKSON MEMORIAL HOSPITAL",
        "enumeration_date": "2014-11-26",
        "last_updated": "2021-10-18",
        "certification_date": "2021-10-18",
        "status": "A",
        "authorized_official_last_name": "STUART",
        "authorized_official_first_name": "DANIELLE",
        "authorized_official_title_or_position": "CREDENTIALING REPRESENTATIVE 2",
        "authorized_official_telephone_number": "601-200-4880"
    },
    "taxonomies": [
        {
            "code": "363LF0000X",
            "taxonomy_group": "193200000X MULTI-SPECIALTY GROUP",
            "desc": "Nurse Practitioner, Family",
            "state": "MS",
            "license": "R886071",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "04838265",
            "state": "MS"
        }
    ],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "St. Dominic Family Practice Associates-Jackson",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

Other providers in Jackson, MS

Sources for this page

  • NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Oct 18, 2021; 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.