Provider Demographics
NPI:1902650195
Name:CIACCI, JENSEN (PA)
Entity type:Individual
Prefix:
First Name:JENSEN
Middle Name:
Last Name:CIACCI
Suffix:
Gender:F
Credentials:PA
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 247
Mailing Address - Street 2:
Mailing Address - City:LAUREL
Mailing Address - State:MS
Mailing Address - Zip Code:39441-0247
Mailing Address - Country:US
Mailing Address - Phone:601-425-7550
Mailing Address - Fax:
Practice Address - Street 1:1002 JEFFERSON STREET
Practice Address - Street 2:STE 400
Practice Address - City:LAUREL
Practice Address - State:MS
Practice Address - Zip Code:39440
Practice Address - Country:US
Practice Address - Phone:601-649-7802
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-04-15
Last Update Date:2024-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant