Provider Demographics
NPI:1790019354
Name:EDWARDS, JENNIFER BROOKE (FNP)
Entity Type:Individual
Prefix:MRS
First Name:JENNIFER
Middle Name:BROOKE
Last Name:EDWARDS
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:136 MARION AVE
Mailing Address - Street 2:
Mailing Address - City:MCCOMB
Mailing Address - State:MS
Mailing Address - Zip Code:39648-3620
Mailing Address - Country:US
Mailing Address - Phone:601-684-3210
Mailing Address - Fax:601-684-3319
Practice Address - Street 1:136 MARION AVE
Practice Address - Street 2:
Practice Address - City:MCCOMB
Practice Address - State:MS
Practice Address - Zip Code:39648-3620
Practice Address - Country:US
Practice Address - Phone:601-684-3210
Practice Address - Fax:601-684-3319
Is Sole Proprietor?:No
Enumeration Date:2009-09-29
Last Update Date:2013-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSR875038363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS302I505818Medicare PIN
MS302I505586Medicare PIN