Provider Demographics
NPI:1083246474
Name:GOODWIN, JENNIFER ROSS (PNP-PC)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:ROSS
Last Name:GOODWIN
Suffix:
Gender:F
Credentials:PNP-PC
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 1729
Mailing Address - Street 2:
Mailing Address - City:HATTIESBURG
Mailing Address - State:MS
Mailing Address - Zip Code:39403-1729
Mailing Address - Country:US
Mailing Address - Phone:601-450-3030
Mailing Address - Fax:601-450-3031
Practice Address - Street 1:424 MARTIN LUTHER KING DR
Practice Address - Street 2:
Practice Address - City:PURVIS
Practice Address - State:MS
Practice Address - Zip Code:39475-5028
Practice Address - Country:US
Practice Address - Phone:601-545-8700
Practice Address - Fax:601-450-0231
Is Sole Proprietor?:No
Enumeration Date:2020-02-04
Last Update Date:2024-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS865754163W00000X, 363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics
No163W00000XNursing Service ProvidersRegistered Nurse