Provider Demographics
NPI:1457754855
Name:PATTIE, JENNIFER FARRIS (MSN, FNP-C)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:FARRIS
Last Name:PATTIE
Suffix:
Gender:F
Credentials:MSN, FNP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:415 S 28TH AVE
Mailing Address - Street 2:
Mailing Address - City:HATTIESBURG
Mailing Address - State:MS
Mailing Address - Zip Code:39401-7246
Mailing Address - Country:US
Mailing Address - Phone:601-261-1500
Mailing Address - Fax:601-579-5240
Practice Address - Street 1:7148 US HIGHWAY 98
Practice Address - Street 2:SUITE101
Practice Address - City:HATTIESBURG
Practice Address - State:MS
Practice Address - Zip Code:39402
Practice Address - Country:US
Practice Address - Phone:601-261-1500
Practice Address - Fax:601-296-7549
Is Sole Proprietor?:Yes
Enumeration Date:2014-09-30
Last Update Date:2020-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS888276363L00000X, 363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS09126379Medicaid