Provider Demographics
NPI:1144416504
Name:RUSSELL, JODI HARDY (FNP)
Entity Type:Individual
Prefix:
First Name:JODI
Middle Name:HARDY
Last Name:RUSSELL
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:107 EUREKA ST
Mailing Address - Street 2:
Mailing Address - City:BATESVILLE
Mailing Address - State:MS
Mailing Address - Zip Code:38606-2533
Mailing Address - Country:US
Mailing Address - Phone:662-563-6000
Mailing Address - Fax:662-563-0700
Practice Address - Street 1:107 EUREKA ST
Practice Address - Street 2:
Practice Address - City:BATESVILLE
Practice Address - State:MS
Practice Address - Zip Code:38606-2533
Practice Address - Country:US
Practice Address - Phone:662-563-6000
Practice Address - Fax:662-563-0700
Is Sole Proprietor?:No
Enumeration Date:2007-09-19
Last Update Date:2019-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSR861526363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS03428243Medicaid
MS512I500356OtherPROVIDER TRANSACTION ACCESS NUMBER/PTAN