Provider Demographics
NPI:1164683702
Name:RICHARDSON, JENNIFER (NNP)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:
Last Name:RICHARDSON
Suffix:
Gender:F
Credentials:NNP
Other - Prefix:MRS
Other - First Name:JENNIFER
Other - Middle Name:
Other - Last Name:RICHARDSON
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:NNP-BC
Mailing Address - Street 1:1991 LAKELAND DR STE C
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:MS
Mailing Address - Zip Code:39216-5000
Mailing Address - Country:US
Mailing Address - Phone:601-981-5887
Mailing Address - Fax:601-981-7935
Practice Address - Street 1:1991 LAKELAND DR STE C
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:MS
Practice Address - Zip Code:39216-5000
Practice Address - Country:US
Practice Address - Phone:601-981-5887
Practice Address - Fax:601-981-7935
Is Sole Proprietor?:No
Enumeration Date:2008-06-17
Last Update Date:2012-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSR855650363LN0005X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LN0005XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerNeonatal, Critical Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS06939583Medicaid
MS06939583Medicaid
MS30250I9108Medicare PIN