Provider Demographics
NPI:1780104646
Name:DEAN, JAMIE SIMONSON (AGACNP)
Entity type:Individual
Prefix:
First Name:JAMIE
Middle Name:SIMONSON
Last Name:DEAN
Suffix:
Gender:F
Credentials:AGACNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:172 CLEARVIEW DR E
Mailing Address - Street 2:
Mailing Address - City:MADISON
Mailing Address - State:MS
Mailing Address - Zip Code:39110-4542
Mailing Address - Country:US
Mailing Address - Phone:601-613-4154
Mailing Address - Fax:
Practice Address - Street 1:350 W WOODROW WILSON AVE
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:MS
Practice Address - Zip Code:39213-7681
Practice Address - Country:US
Practice Address - Phone:601-984-5615
Practice Address - Fax:601-984-5689
Is Sole Proprietor?:No
Enumeration Date:2017-06-22
Last Update Date:2017-06-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSR885616363LA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care