Provider Demographics
NPI:1558018598
Name:JIMMERSON, CAROLYN J
Entity Type:Individual
Prefix:
First Name:CAROLYN
Middle Name:J
Last Name:JIMMERSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:102 RIVERVIEW DR STE A
Mailing Address - Street 2:
Mailing Address - City:FLOWOOD
Mailing Address - State:MS
Mailing Address - Zip Code:39232-8908
Mailing Address - Country:US
Mailing Address - Phone:601-981-1610
Mailing Address - Fax:601-366-2887
Practice Address - Street 1:102 RIVERVIEW DR STE A
Practice Address - Street 2:
Practice Address - City:FLOWOOD
Practice Address - State:MS
Practice Address - Zip Code:39232-8908
Practice Address - Country:US
Practice Address - Phone:601-981-1610
Practice Address - Fax:601-366-2887
Is Sole Proprietor?:No
Enumeration Date:2022-03-09
Last Update Date:2022-12-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSR868951163WG0000X
MS905623363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163WG0000XNursing Service ProvidersRegistered NurseGeneral Practice