Provider Demographics
NPI:1568473270
Name:BRISTER, JACKIE EUGENE (FNP)
Entity type:Individual
Prefix:
First Name:JACKIE
Middle Name:EUGENE
Last Name:BRISTER
Suffix:
Gender:M
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:PO BOX 1909
Mailing Address - Street 2:
Mailing Address - City:MCCOMB
Mailing Address - State:MS
Mailing Address - Zip Code:39649-1909
Mailing Address - Country:US
Mailing Address - Phone:601-250-1122
Mailing Address - Fax:601-250-0290
Practice Address - Street 1:1017 DELAWARE AVE
Practice Address - Street 2:
Practice Address - City:MCCOMB
Practice Address - State:MS
Practice Address - Zip Code:39648-3827
Practice Address - Country:US
Practice Address - Phone:601-250-1122
Practice Address - Fax:601-250-0290
Is Sole Proprietor?:No
Enumeration Date:2006-08-10
Last Update Date:2008-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSR862702363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
MSQ71273Medicare UPIN
MS1568473270Medicare NSC