Provider Demographics
NPI:1063180420
Name:SMITH, JENNIFER D (FNP)
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:D
Last Name:SMITH
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1005 W CONGRESS ST
Mailing Address - Street 2:
Mailing Address - City:BROOKHAVEN
Mailing Address - State:MS
Mailing Address - Zip Code:39601-2603
Mailing Address - Country:US
Mailing Address - Phone:601-833-9388
Mailing Address - Fax:601-833-9495
Practice Address - Street 1:1005 W CONGRESS ST
Practice Address - Street 2:
Practice Address - City:BROOKHAVEN
Practice Address - State:MS
Practice Address - Zip Code:39601-2603
Practice Address - Country:US
Practice Address - Phone:601-833-9388
Practice Address - Fax:601-833-9495
Is Sole Proprietor?:No
Enumeration Date:2021-09-01
Last Update Date:2021-09-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS904854363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner