Provider Demographics
NPI:1588028153
Name:STANFORD, JENNIE THOMAS (MD)
Entity Type:Individual
Prefix:DR
First Name:JENNIE
Middle Name:THOMAS
Last Name:STANFORD
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 1:110 MILLSAPS DR
Mailing Address - Street 2:
Mailing Address - City:HATTIESBURG
Mailing Address - State:MS
Mailing Address - Zip Code:39402-1347
Mailing Address - Country:US
Mailing Address - Phone:601-296-2712
Mailing Address - Fax:
Practice Address - Street 1:110 MILLSAPS DR
Practice Address - Street 2:
Practice Address - City:HATTIESBURG
Practice Address - State:MS
Practice Address - Zip Code:39402-1347
Practice Address - Country:US
Practice Address - Phone:601-296-2712
Practice Address - Fax:601-450-6045
Is Sole Proprietor?:No
Enumeration Date:2016-04-11
Last Update Date:2021-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS26586207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS07129501Medicaid