Jea Surgical, LLC

Primary specialty

Ambulatory Surgical Clinic/CenterTaxonomy code 261QA1903X

Legal business name

JEA SURGICAL, LLC

Practice address

1026 Baptist Circle
Suite 101
Madison, MS 39110

Phone

(601) 353-2020

NPI assigned

Jan 8, 2024

Organization subpart

No

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

Authorized official

Name

Shane Humphries

Title

Practice Administrator

Phone

(601) 353-2020

Specialties & licenses 2

Addresses

Medicare fee-for-service enrollment

Enrolled in MS

Enrollment records 1

NPI to CCN mapping 1

The Medicare certification numbers (CCNs) connected to NPI 1669242822. Details of each certification follow.

• CCN 25C0001106 Ambulatory surgical center · Active · Name & address match · Details

Ambulatory surgical center certification: CCN 25C0001106

Legal name

JEA Surgical, LLC

Certification status

Active

Provider type (POS)

Ambulatory surgical center

Participating since

Aug 20, 2024

Last certification

Aug 20, 2024

Ownership / control type

Proprietary

Facility address

1026 Baptist Circle
Madison, MS 39110

These CMS records do not include an NPI. They are shown because their name and street address match this provider’s.

CLIA laboratory certificates

Locations

Practitioners 1

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.

• Robert A Mallette, M.D.

  • Ophthalmology Physician
  • Jackson, MS
  • NPI 1205831914
  NPD (past)

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

{
    "created_epoch": "1704672000000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1749772800000",
    "number": "1669242822",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "1026 BAPTIST CIR STE 101",
            "city": "MADISON",
            "state": "MS",
            "postal_code": "391102028",
            "telephone_number": "601-353-2020",
            "fax_number": "769-567-1069"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "1026 BAPTIST CIRCLE",
            "address_2": "SUITE 101",
            "city": "MADISON",
            "state": "MS",
            "postal_code": "39110",
            "telephone_number": "601-353-2020"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "JEA SURGICAL, LLC",
        "organizational_subpart": "NO",
        "enumeration_date": "2024-01-08",
        "last_updated": "2025-06-13",
        "certification_date": "2025-06-13",
        "status": "A",
        "authorized_official_last_name": "HUMPHRIES",
        "authorized_official_first_name": "SHANE",
        "authorized_official_title_or_position": "PRACTICE ADMINISTRATOR",
        "authorized_official_telephone_number": "601-353-2020"
    },
    "taxonomies": [
        {
            "code": "207W00000X",
            "taxonomy_group": "193400000X SINGLE SPECIALTY  GROUP",
            "desc": "Ophthalmology",
            "state": null,
            "license": null,
            "primary": false
        },
        {
            "code": "261QA1903X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Ambulatory Surgical",
            "state": null,
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

• William Dotie Jackson, MD
• Julia Lane Jacobi, DMD
• Glenn E James, M.D.
• Taylor Cannon James, FNP-C
• Jea Optical LLC
• Fanasy Prokop Jefcoat, D.M.D., MS
• Taylor Cecile Illyana Jefferson
• Jeffery P Jones DC
• Traves Jeffery, COTA
• Jordan Larue Fulcher Jenkins, FNP-C

• Ambulatory Surgical Clinic/Center in Madison, MS
• Providers in Madison, MS by specialty
• Ambulatory Surgical Clinic/Center in Mississippi

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Jun 13, 2025; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments; facility enrollments, owners and changes of ownership; Provider of Services certification data.
• Medicare Care Compare (CMS): clinician profile, group practices, facility affiliations, MIPS scores and star ratings.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.