Provider Demographics
NPI:1376813220
Name:MARKS, JEAN PENNINGTON (GNP-BC)
Entity Type:Individual
Prefix:
First Name:JEAN
Middle Name:PENNINGTON
Last Name:MARKS
Suffix:
Gender:F
Credentials:GNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:315 E CENTER ST
Mailing Address - Street 2:
Mailing Address - City:CANTON
Mailing Address - State:MS
Mailing Address - Zip Code:39046-3803
Mailing Address - Country:US
Mailing Address - Phone:601-855-0223
Mailing Address - Fax:
Practice Address - Street 1:115 W MADISON ST
Practice Address - Street 2:
Practice Address - City:BOLTON
Practice Address - State:MS
Practice Address - Zip Code:39041-3209
Practice Address - Country:US
Practice Address - Phone:601-866-7723
Practice Address - Fax:601-866-7773
Is Sole Proprietor?:Yes
Enumeration Date:2012-01-10
Last Update Date:2012-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSR860036363LG0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MSR860036OtherLICENSE NUMBER