Provider Demographics
NPI:1629199633
Name:FRAISER, JACQUELINE A (CRNP)
Entity Type:Individual
Prefix:MRS
First Name:JACQUELINE
Middle Name:A
Last Name:FRAISER
Suffix:
Gender:F
Credentials:CRNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2601 GETWELL RD
Mailing Address - Street 2:STE 1
Mailing Address - City:CORINTH
Mailing Address - State:MS
Mailing Address - Zip Code:38834-6762
Mailing Address - Country:US
Mailing Address - Phone:662-287-7138
Mailing Address - Fax:662-287-7157
Practice Address - Street 1:2601 GETWELL RD STE 1
Practice Address - Street 2:
Practice Address - City:CORINTH
Practice Address - State:MS
Practice Address - Zip Code:38834-6762
Practice Address - Country:US
Practice Address - Phone:662-287-7138
Practice Address - Fax:662-287-7157
Is Sole Proprietor?:No
Enumeration Date:2007-04-03
Last Update Date:2021-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSR851578363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS02488503Medicaid
MS02488503Medicaid