Provider Demographics
NPI:1679203863
Name:MOONEY, JENNIFER NICOLE (DMD)
Entity Type:Individual
Prefix:DR
First Name:JENNIFER
Middle Name:NICOLE
Last Name:MOONEY
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:209 RIVERWIND DR
Mailing Address - Street 2:
Mailing Address - City:PEARL
Mailing Address - State:MS
Mailing Address - Zip Code:39208-5653
Mailing Address - Country:US
Mailing Address - Phone:601-936-6161
Mailing Address - Fax:
Practice Address - Street 1:209 RIVERWIND DR
Practice Address - Street 2:
Practice Address - City:PEARL
Practice Address - State:MS
Practice Address - Zip Code:39208-5653
Practice Address - Country:US
Practice Address - Phone:601-936-6161
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-06-13
Last Update Date:2022-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS4287-221223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice