Provider Demographics
NPI:1124660063
Name:PUGH, JENNA BROOKE (FNP)
Entity type:Individual
Prefix:
First Name:JENNA
Middle Name:BROOKE
Last Name:PUGH
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 1:2160 COUNTY ROAD 130
Mailing Address - Street 2:
Mailing Address - City:CARROLLTON
Mailing Address - State:MS
Mailing Address - Zip Code:38917-5731
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2160 COUNTY ROAD 130
Practice Address - Street 2:
Practice Address - City:CARROLLTON
Practice Address - State:MS
Practice Address - Zip Code:38917-5731
Practice Address - Country:US
Practice Address - Phone:662-299-5366
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-10-11
Last Update Date:2019-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS903532363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily