Provider Demographics
NPI:1417415027
Name:KITTLER, JENNIFER LYNNE (RN, FNP)
Entity Type:Individual
Prefix:MRS
First Name:JENNIFER
Middle Name:LYNNE
Last Name:KITTLER
Suffix:
Gender:F
Credentials:RN, FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
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:601-358-9630
Mailing Address - Fax:601-579-5240
Practice Address - Street 1:128 HIGHLAND PKWY STE 200
Practice Address - Street 2:
Practice Address - City:PICAYUNE
Practice Address - State:MS
Practice Address - Zip Code:39466-5578
Practice Address - Country:US
Practice Address - Phone:601-358-9630
Practice Address - Fax:601-358-9640
Is Sole Proprietor?:Yes
Enumeration Date:2019-03-04
Last Update Date:2019-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS903118363L00000X, 363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS04321700Medicaid