Provider Demographics
NPI:1407682420
Name:SULLIVAN, JESSICA (CFNP)
Entity type:Individual
Prefix:
First Name:JESSICA
Middle Name:
Last Name:SULLIVAN
Suffix:
Gender:F
Credentials:CFNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:18780 HIGHWAY 46
Mailing Address - Street 2:
Mailing Address - City:MANTEE
Mailing Address - State:MS
Mailing Address - Zip Code:39751-9514
Mailing Address - Country:US
Mailing Address - Phone:662-295-1944
Mailing Address - Fax:662-456-7335
Practice Address - Street 1:120 MARKET ST
Practice Address - Street 2:
Practice Address - City:WOODLAND
Practice Address - State:MS
Practice Address - Zip Code:39776-9104
Practice Address - Country:US
Practice Address - Phone:662-456-0111
Practice Address - Fax:662-456-7335
Is Sole Proprietor?:No
Enumeration Date:2024-09-09
Last Update Date:2024-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS906933363LP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary Care