MEDICARE: VIRGINIA POOLE GENTRY

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363LF0000X	Family Nurse Practitioner	902817	MS

General Provider Information

NPI Number	:	1831762442
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	VIRGINIA POOLE GENTRY

Provider Business Mailing Address
First Line	:	1190 N STATE ST STE 202
Second Line	:
City	:	JACKSON
State	:	MS
Zip	:	39202-2463
Country	:	US
Telephone Number	:	601-968-0896
Fax Number	:

Provider Business Practice Location Address
First Line	:	1190 N STATE ST STE 202
Second Line	:
City	:	JACKSON
State	:	MS
Zip	:	39202-2463
Country	:	US
Telephone Number	:	601-968-0896
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/21/2021
Last Update Date	:	08/16/2021

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Directions to “ VIRGINIA POOLE GENTRY ” Practice Location

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