Provider Demographics
NPI:1114318987
Name:CARPENTER, JAMIE L (FNP-C)
Entity Type:Individual
Prefix:
First Name:JAMIE
Middle Name:L
Last Name:CARPENTER
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 1:7145 GOODMAN RD
Mailing Address - Street 2:
Mailing Address - City:OLIVE BRANCH
Mailing Address - State:MS
Mailing Address - Zip Code:38654-1904
Mailing Address - Country:US
Mailing Address - Phone:662-333-5001
Mailing Address - Fax:662-420-7063
Practice Address - Street 1:7145 GOODMAN RD
Practice Address - Street 2:
Practice Address - City:OLIVE BRANCH
Practice Address - State:MS
Practice Address - Zip Code:38654-1904
Practice Address - Country:US
Practice Address - Phone:662-333-5001
Practice Address - Fax:662-420-7063
Is Sole Proprietor?:No
Enumeration Date:2015-02-13
Last Update Date:2018-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN163971163W00000X
TN19660363LF0000X
MS902936363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No163W00000XNursing Service ProvidersRegistered Nurse
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS02374577Medicaid