Provider Demographics
NPI:1467952069
Name:TRUMP, JENNIFER (NP)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:
Last Name:TRUMP
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14594 BRUCE CV S
Mailing Address - Street 2:
Mailing Address - City:DIBERVILLE
Mailing Address - State:MS
Mailing Address - Zip Code:39540-5824
Mailing Address - Country:US
Mailing Address - Phone:601-307-8603
Mailing Address - Fax:
Practice Address - Street 1:14116 CUSTOMS BLVD STE 113
Practice Address - Street 2:
Practice Address - City:GULFPORT
Practice Address - State:MS
Practice Address - Zip Code:39503-5165
Practice Address - Country:US
Practice Address - Phone:833-362-6703
Practice Address - Fax:855-362-0778
Is Sole Proprietor?:No
Enumeration Date:2018-02-20
Last Update Date:2021-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS902531363LA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS03659322Medicaid