Provider Demographics
NPI:1073797338
Name:GODBOLD, JENNIFER SUMRALL (APRN, BC)
Entity Type:Individual
Prefix:MRS
First Name:JENNIFER
Middle Name:SUMRALL
Last Name:GODBOLD
Suffix:
Gender:F
Credentials:APRN, BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2500 N STATE ST
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:MS
Mailing Address - Zip Code:39216-4500
Mailing Address - Country:US
Mailing Address - Phone:601-984-5678
Mailing Address - Fax:601-984-5638
Practice Address - Street 1:2500 NORTH STATE STREET
Practice Address - Street 2:SURGERY
Practice Address - City:JACKSON
Practice Address - State:MS
Practice Address - Zip Code:39216
Practice Address - Country:US
Practice Address - Phone:601-984-5678
Practice Address - Fax:601-984-5638
Is Sole Proprietor?:No
Enumeration Date:2007-12-21
Last Update Date:2014-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSR865457363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS05956046Medicaid
MS378205YS8TMedicare PIN
MS302I508758Medicare PIN
MS512I500451Medicare PIN