Provider Demographics
NPI:1568493450
Name:SHORES, JENNIFER C (MD)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:C
Last Name:SHORES
Suffix:
Gender:F
Credentials:MD
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:601-984-5250
Mailing Address - Fax:601-984-5283
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:601-984-5250
Practice Address - Fax:601-984-5283
Is Sole Proprietor?:No
Enumeration Date:2006-07-06
Last Update Date:2014-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS170222080P0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080P0202XAllopathic & Osteopathic PhysiciansPediatricsPediatric Cardiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS0123172Medicaid
AL158189Medicaid
MS302I379140Medicare PIN
MS370000318Medicare ID - Type Unspecified
MS0123172Medicaid
AL158189Medicaid