Provider Demographics
NPI:1962870253
Name:ANTHONY, JENA WADE (FNP-C)
Entity type:Individual
Prefix:MRS
First Name:JENA
Middle Name:WADE
Last Name:ANTHONY
Suffix:
Gender:F
Credentials:FNP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5338 MS HIGHWAY 9
Mailing Address - Street 2:
Mailing Address - City:EUPORA
Mailing Address - State:MS
Mailing Address - Zip Code:39744-8606
Mailing Address - Country:US
Mailing Address - Phone:662-983-8438
Mailing Address - Fax:
Practice Address - Street 1:457 E MADISON ST
Practice Address - Street 2:
Practice Address - City:HOUSTON
Practice Address - State:MS
Practice Address - Zip Code:38851-2308
Practice Address - Country:US
Practice Address - Phone:662-567-5005
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-09-03
Last Update Date:2015-09-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSR882626363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily