Provider Demographics
NPI:1588053052
Name:COLE, JUSTIN (NP)
Entity type:Individual
Prefix:
First Name:JUSTIN
Middle Name:
Last Name:COLE
Suffix:
Gender:M
Credentials:NP
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 23666
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:MS
Mailing Address - Zip Code:39225-3666
Mailing Address - Country:US
Mailing Address - Phone:601-200-4560
Mailing Address - Fax:601-200-4580
Practice Address - Street 1:1203 JEFFERSON ST
Practice Address - Street 2:
Practice Address - City:LAUREL
Practice Address - State:MS
Practice Address - Zip Code:39440-4354
Practice Address - Country:US
Practice Address - Phone:601-649-2863
Practice Address - Fax:601-649-9479
Is Sole Proprietor?:No
Enumeration Date:2015-01-21
Last Update Date:2021-05-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSR885111363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner