Provider Demographics
NPI:1386883791
Name:MORAN, JESSICA HAVARD (FNP-BC)
Entity type:Individual
Prefix:MRS
First Name:JESSICA
Middle Name:HAVARD
Last Name:MORAN
Suffix:
Gender:F
Credentials:FNP-BC
Other - Prefix:MRS
Other - First Name:JESSICA
Other - Middle Name:LEIGH
Other - Last Name:HAVARD
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:FNP-BC
Mailing Address - Street 1:5501 MARVIN SHIELDS BLVD BLDG 472
Mailing Address - Street 2:
Mailing Address - City:GULFPORT
Mailing Address - State:MS
Mailing Address - Zip Code:39501-9007
Mailing Address - Country:US
Mailing Address - Phone:228-871-4033
Mailing Address - Fax:
Practice Address - Street 1:5501 MARVIN SHIELDS BLVD BLDG 472
Practice Address - Street 2:
Practice Address - City:GULFPORT
Practice Address - State:MS
Practice Address - Zip Code:39501-9007
Practice Address - Country:US
Practice Address - Phone:228-871-4033
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-02-09
Last Update Date:2022-07-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSR871245363LF0000X, 363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS08821006Medicaid