Provider Demographics
NPI:1205076809
Name:MASSEY, JENNIFER R (CNNP)
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:R
Last Name:MASSEY
Suffix:
Gender:F
Credentials:CNNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:81 RED MAPLE TRL
Mailing Address - Street 2:
Mailing Address - City:PETAL
Mailing Address - State:MS
Mailing Address - Zip Code:39465-4430
Mailing Address - Country:US
Mailing Address - Phone:601-466-6469
Mailing Address - Fax:
Practice Address - Street 1:6049 U S HIGHWAY 49
Practice Address - Street 2:
Practice Address - City:HATTIESBURG
Practice Address - State:MS
Practice Address - Zip Code:39402-2555
Practice Address - Country:US
Practice Address - Phone:601-288-3440
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-02-23
Last Update Date:2009-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSR872528363LN0005X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LN0005XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerNeonatal, Critical Care