Provider Demographics
NPI:1467095869
Name:CHILDS, JESSICA BRADDOCK (AGNP)
Entity Type:Individual
Prefix:MRS
First Name:JESSICA
Middle Name:BRADDOCK
Last Name:CHILDS
Suffix:
Gender:F
Credentials:AGNP
Other - Prefix:MISS
Other - First Name:JESSICA
Other - Middle Name:MICHELLE
Other - Last Name:BRADDOCK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RN
Mailing Address - Street 1:1265 CLIFF GOOKIN BLVD
Mailing Address - Street 2:
Mailing Address - City:TUPELO
Mailing Address - State:MS
Mailing Address - Zip Code:38801-6749
Mailing Address - Country:US
Mailing Address - Phone:662-407-2544
Mailing Address - Fax:662-620-9915
Practice Address - Street 1:1265 CLIFF GOOKIN BLVD
Practice Address - Street 2:
Practice Address - City:TUPELO
Practice Address - State:MS
Practice Address - Zip Code:38801-6749
Practice Address - Country:US
Practice Address - Phone:662-407-2544
Practice Address - Fax:662-620-9915
Is Sole Proprietor?:Yes
Enumeration Date:2019-10-18
Last Update Date:2022-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSR874853163W00000X
MS905426363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
No163W00000XNursing Service ProvidersRegistered Nurse