Provider Demographics
NPI:1184958969
Name:BOUTWELL, JENNIFER R (FNP)
Entity type:Individual
Prefix:MRS
First Name:JENNIFER
Middle Name:R
Last Name:BOUTWELL
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 1:303 MARION AVE
Mailing Address - Street 2:
Mailing Address - City:MCCOMB
Mailing Address - State:MS
Mailing Address - Zip Code:39648-2707
Mailing Address - Country:US
Mailing Address - Phone:601-249-1350
Mailing Address - Fax:601-249-1339
Practice Address - Street 1:303 MARION AVE
Practice Address - Street 2:
Practice Address - City:MCCOMB
Practice Address - State:MS
Practice Address - Zip Code:39648-2707
Practice Address - Country:US
Practice Address - Phone:601-249-1350
Practice Address - Fax:601-249-1339
Is Sole Proprietor?:Yes
Enumeration Date:2009-09-25
Last Update Date:2009-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSR880925363LA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care