Provider Demographics
NPI:1457660961
Name:HOWARD, JENETRIA THOMAS (FNP)
Entity Type:Individual
Prefix:MRS
First Name:JENETRIA
Middle Name:THOMAS
Last Name:HOWARD
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:MS
Other - First Name:JENETRIA
Other - Middle Name:LASHUN
Other - Last Name:THOMAS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:FNP
Mailing Address - Street 1:7559 IRON LOOP
Mailing Address - Street 2:
Mailing Address - City:OLIVE BRANCH
Mailing Address - State:MS
Mailing Address - Zip Code:38654-1047
Mailing Address - Country:US
Mailing Address - Phone:601-421-7433
Mailing Address - Fax:
Practice Address - Street 1:877 JEFFERSON AVE
Practice Address - Street 2:
Practice Address - City:MEMPHIS
Practice Address - State:TN
Practice Address - Zip Code:38103-2807
Practice Address - Country:US
Practice Address - Phone:901-545-7100
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-09-30
Last Update Date:2021-03-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209-009035363L00000X
TN246912363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
302I505779OtherMEDICARE ( PTAN)
IL209009035OtherADVANCED PRACTICE NURSE LICENSE
MS04927367Medicaid
IL041396248OtherREGISTERED NURSE LICENSE