Provider Demographics
NPI:1689696627
Name:STUCKEY, JACKIE B (CFNP)
Entity Type:Individual
Prefix:
First Name:JACKIE
Middle Name:B
Last Name:STUCKEY
Suffix:
Gender:F
Credentials:CFNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 669
Mailing Address - Street 2:
Mailing Address - City:FOXWORTH
Mailing Address - State:MS
Mailing Address - Zip Code:39483
Mailing Address - Country:US
Mailing Address - Phone:601-424-3540
Mailing Address - Fax:601-424-3544
Practice Address - Street 1:62 HIGHWAY 587
Practice Address - Street 2:
Practice Address - City:FOXWORTH
Practice Address - State:MS
Practice Address - Zip Code:39483
Practice Address - Country:US
Practice Address - Phone:601-424-3540
Practice Address - Fax:601-424-3544
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-25
Last Update Date:2013-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSR805328363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS09372826Medicaid
MSQ47562Medicare UPIN
MS09372826Medicaid