Provider Demographics
NPI:1306518477
Name:SULLIVAN, JACQUELYN (NP)
Entity type:Individual
Prefix:
First Name:JACQUELYN
Middle Name:
Last Name:SULLIVAN
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:JACQUELYN
Other - Middle Name:LEE
Other - Last Name:RICHARDSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2101 HIGHWAY 90
Mailing Address - Street 2:
Mailing Address - City:GAUTIER
Mailing Address - State:MS
Mailing Address - Zip Code:39553-5340
Mailing Address - Country:US
Mailing Address - Phone:228-497-7576
Mailing Address - Fax:228-497-8869
Practice Address - Street 1:1270 OCEAN SPRINGS RD
Practice Address - Street 2:
Practice Address - City:OCEAN SPRINGS
Practice Address - State:MS
Practice Address - Zip Code:39564-3409
Practice Address - Country:US
Practice Address - Phone:228-875-3033
Practice Address - Fax:228-875-3989
Is Sole Proprietor?:No
Enumeration Date:2021-09-28
Last Update Date:2021-11-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS904843363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily