Provider Demographics
NPI:1235529454
Name:CHAMPAGNE, JENNIFER (NP-C)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:
Last Name:CHAMPAGNE
Suffix:
Gender:F
Credentials:NP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:30030 ROAD 202
Mailing Address - Street 2:
Mailing Address - City:CARRIERE
Mailing Address - State:MS
Mailing Address - Zip Code:39426-9208
Mailing Address - Country:US
Mailing Address - Phone:601-590-1459
Mailing Address - Fax:
Practice Address - Street 1:2797 COOPER RD
Practice Address - Street 2:
Practice Address - City:PICAYUNE
Practice Address - State:MS
Practice Address - Zip Code:39466-2213
Practice Address - Country:US
Practice Address - Phone:601-799-1616
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-01-26
Last Update Date:2016-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSR871326363LA2200X, 363LG0600X, 363LP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
No363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontology
No363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary Care