Healthcare Provider Details

I. General information

NPI: 1053129080
Provider Name (Legal Business Name): JACOLYN ALYSE ROBINSON FNP-BC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/23/2024
Last Update Date: 12/23/2024
Certification Date: 12/22/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

105 WOODMOOR CV
CLINTON MS
39056-4155
US

IV. Provider business mailing address

105 WOODMOOR CV
CLINTON MS
39056-4155
US

V. Phone/Fax

Practice location:
  • Phone: 601-899-2981
  • Fax:
Mailing address:
  • Phone: 601-899-2981
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number906546
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: