Provider Demographics
NPI:1063848638
Name:ESTOCK, JENNIFER G (WHNP-BC, ANP-C)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:G
Last Name:ESTOCK
Suffix:
Gender:F
Credentials:WHNP-BC, ANP-C
Other - Prefix:
Other - First Name:JENNIFER
Other - Middle Name:
Other - Last Name:CARWILE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:WHNP-BC, ANP-C
Mailing Address - Street 1:499 GLOSTER CREEK VLG
Mailing Address - Street 2:SUITE D-1
Mailing Address - City:TUPELO
Mailing Address - State:MS
Mailing Address - Zip Code:38801-4600
Mailing Address - Country:US
Mailing Address - Phone:662-690-8007
Mailing Address - Fax:662-842-4653
Practice Address - Street 1:499 GLOSTER CREEK VLG
Practice Address - Street 2:SUITE D-1
Practice Address - City:TUPELO
Practice Address - State:MS
Practice Address - Zip Code:38801-4600
Practice Address - Country:US
Practice Address - Phone:662-690-8007
Practice Address - Fax:662-842-4653
Is Sole Proprietor?:No
Enumeration Date:2013-09-16
Last Update Date:2014-11-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSR861901363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS09987864Medicaid
MS319704YSTLMedicare PIN