Provider Demographics
NPI:1497052211
Name:MCDANIEL, JENNIFER EDEN (CPNP-AC)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:EDEN
Last Name:MCDANIEL
Suffix:
Gender:F
Credentials:CPNP-AC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2500 N STATE ST
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:MS
Mailing Address - Zip Code:39216-4500
Mailing Address - Country:US
Mailing Address - Phone:601-815-8151
Mailing Address - Fax:601-815-8152
Practice Address - Street 1:2500 N STATE ST
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:MS
Practice Address - Zip Code:39216-4500
Practice Address - Country:US
Practice Address - Phone:601-815-8151
Practice Address - Fax:601-815-8152
Is Sole Proprietor?:Yes
Enumeration Date:2011-02-14
Last Update Date:2017-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSR858523363LP0222X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0222XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics, Critical Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS30250I5892Medicare PIN
MS302I508807Medicare PIN