Provider Demographics
NPI:1114599941
Name:EVANS, JENNIFER BROOK (RN)
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:BROOK
Last Name:EVANS
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:JENNIFER
Other - Middle Name:BROOK
Other - Last Name:EVANS
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:RN
Mailing Address - Street 1:212 RAMPART ST
Mailing Address - Street 2:
Mailing Address - City:RIDGELAND
Mailing Address - State:MS
Mailing Address - Zip Code:39157-3564
Mailing Address - Country:US
Mailing Address - Phone:601-863-9118
Mailing Address - Fax:
Practice Address - Street 1:2500 N STATE ST
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:MS
Practice Address - Zip Code:39216-4500
Practice Address - Country:US
Practice Address - Phone:601-815-1552
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-07-12
Last Update Date:2021-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSR836876163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse