Provider Demographics
NPI:1811303670
Name:WALLER, JODI (FNP-C)
Entity type:Individual
Prefix:
First Name:JODI
Middle Name:
Last Name:WALLER
Suffix:
Gender:F
Credentials:FNP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1055 ANGLIN RD
Mailing Address - Street 2:
Mailing Address - City:SUMMIT
Mailing Address - State:MS
Mailing Address - Zip Code:39666-7018
Mailing Address - Country:US
Mailing Address - Phone:601-303-6809
Mailing Address - Fax:
Practice Address - Street 1:300 RAWLS DR STE 1500
Practice Address - Street 2:
Practice Address - City:MCCOMB
Practice Address - State:MS
Practice Address - Zip Code:39648-2878
Practice Address - Country:US
Practice Address - Phone:855-615-7246
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-07-01
Last Update Date:2014-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSR883312363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily