Provider Demographics
NPI:1003281916
Name:FOREMAN, JENNIFER NICHOLS (A-GNP-C)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:NICHOLS
Last Name:FOREMAN
Suffix:
Gender:F
Credentials:A-GNP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2500 NORTH STATE STREET
Mailing Address - Street 2:JMM ROOM 2525
Mailing Address - City:JACKSON
Mailing Address - State:MS
Mailing Address - Zip Code:39216-4500
Mailing Address - Country:US
Mailing Address - Phone:601-984-6426
Mailing Address - Fax:601-984-6439
Practice Address - Street 1:2500 N STATE ST
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:MS
Practice Address - Zip Code:39216-4500
Practice Address - Country:US
Practice Address - Phone:601-984-5657
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-12-02
Last Update Date:2016-05-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS901418363L00000X
MS882741163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS01604356Medicaid
MS01604356Medicaid