Provider Demographics
NPI:1356646772
Name:STRAYHAM, JILLIAN M (NP)
Entity type:Individual
Prefix:MRS
First Name:JILLIAN
Middle Name:M
Last Name:STRAYHAM
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:JILLIAN
Other - Middle Name:M
Other - Last Name:LADNER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:NP
Mailing Address - Street 1:4500 13TH ST
Mailing Address - Street 2:
Mailing Address - City:GULFPORT
Mailing Address - State:MS
Mailing Address - Zip Code:39501-2515
Mailing Address - Country:US
Mailing Address - Phone:228-239-2296
Mailing Address - Fax:
Practice Address - Street 1:8006 HIGHWAY 613
Practice Address - Street 2:
Practice Address - City:MOSS POINT
Practice Address - State:MS
Practice Address - Zip Code:39562-8200
Practice Address - Country:US
Practice Address - Phone:228-475-1166
Practice Address - Fax:228-475-9337
Is Sole Proprietor?:No
Enumeration Date:2011-01-15
Last Update Date:2021-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSR876026363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS04654891Medicaid