Healthcare Provider Details

I. General information

NPI: 1144687583
Provider Name (Legal Business Name): JERAD ROBINSON
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/15/2016
Last Update Date: 02/18/2026
Certification Date: 02/18/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

606 PROVIDENCE CV
BRANDON MS
39042
US

IV. Provider business mailing address

606 PROVIDENCE CV
BRANDON MS
39042
US

V. Phone/Fax

Practice location:
  • Phone: 601-624-9534
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number882802
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: