Healthcare Provider Details

I. General information

NPI: 1801364526
Provider Name (Legal Business Name): JENNIFER GATES NP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/12/2018
Last Update Date: 11/12/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

606 MCDONALD DR APT G1
CLINTON MS
39056-5303
US

IV. Provider business mailing address

PO BOX 511
CLINTON MS
39060-0511
US

V. Phone/Fax

Practice location:
  • Phone: 601-874-7516
  • Fax:
Mailing address:
  • Phone: 601-248-1472
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number902739
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: