Provider Demographics
NPI:1710959283
Name:DAWSON, JENNIFER LEE (NURSE PRACTITIONER)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:LEE
Last Name:DAWSON
Suffix:
Gender:F
Credentials:NURSE PRACTITIONER
Other - Prefix:
Other - First Name:JENNIFER
Other - Middle Name:STOLSWORTH
Other - Last Name:DAWSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:CRNP
Mailing Address - Street 1:1413 W QUITMAN ST
Mailing Address - Street 2:
Mailing Address - City:IUKA
Mailing Address - State:MS
Mailing Address - Zip Code:38852-1130
Mailing Address - Country:US
Mailing Address - Phone:662-424-9550
Mailing Address - Fax:662-424-9558
Practice Address - Street 1:1413 W QUITMAN ST
Practice Address - Street 2:
Practice Address - City:IUKA
Practice Address - State:MS
Practice Address - Zip Code:38852-1130
Practice Address - Country:US
Practice Address - Phone:662-424-9550
Practice Address - Fax:662-424-9558
Is Sole Proprietor?:No
Enumeration Date:2006-02-07
Last Update Date:2013-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSR860187363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS07950316Medicaid
MSP23834Medicare UPIN
MS07950316Medicaid