Provider Demographics
NPI:1255869665
Name:LACROIX, JENNIFER ELAINE (FNP, RNFA)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:ELAINE
Last Name:LACROIX
Suffix:
Gender:F
Credentials:FNP, RNFA
Other - Prefix:
Other - First Name:JENNIFER
Other - Middle Name:LACROIX
Other - Last Name:GUNTHER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:415 S 28TH AVE
Mailing Address - Street 2:
Mailing Address - City:HATTIESBURG
Mailing Address - State:MS
Mailing Address - Zip Code:39401-7246
Mailing Address - Country:US
Mailing Address - Phone:601-268-5630
Mailing Address - Fax:601-579-5240
Practice Address - Street 1:7148 HWY 98 WEST
Practice Address - Street 2:SUITE 203
Practice Address - City:HATTIESBURG
Practice Address - State:MS
Practice Address - Zip Code:39402
Practice Address - Country:US
Practice Address - Phone:601-268-5630
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-05-30
Last Update Date:2023-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS902195163WR0006X, 363L00000X, 363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163WR0006XNursing Service ProvidersRegistered NurseRegistered Nurse First Assistant
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS08339702Medicaid