Provider Demographics
NPI:1558080739
Name:BASS, JESSICA
Entity type:Individual
Prefix:
First Name:JESSICA
Middle Name:
Last Name:BASS
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2117 BROADWAY DRIVE
Mailing Address - Street 2:
Mailing Address - City:HATTIESBURG
Mailing Address - State:MS
Mailing Address - Zip Code:39402-3210
Mailing Address - Country:US
Mailing Address - Phone:601-288-8050
Mailing Address - Fax:601-288-8058
Practice Address - Street 1:2117 BROADWAY DRIVE
Practice Address - Street 2:
Practice Address - City:HATTIESBURG
Practice Address - State:MS
Practice Address - Zip Code:39402-3210
Practice Address - Country:US
Practice Address - Phone:601-288-8050
Practice Address - Fax:601-288-8058
Is Sole Proprietor?:No
Enumeration Date:2022-08-23
Last Update Date:2025-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS887149363LP0808X
MS821402163WC0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No163WC0200XNursing Service ProvidersRegistered NurseCritical Care Medicine