Healthcare Provider Details

I. General information

NPI: 1013402254
Provider Name (Legal Business Name): JESSICA SUZANNE JENSEN MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: JESSICA SUZANNE NICHOLS

II. Dates (important events)

Enumeration Date: 06/29/2018
Last Update Date: 06/29/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

611 ALCORN DR
CORINTH MS
38834-9321
US

IV. Provider business mailing address

217 COUNTY ROAD 238
IUKA MS
38852-8246
US

V. Phone/Fax

Practice location:
  • Phone: 662-293-1000
  • Fax:
Mailing address:
  • Phone: 901-616-7433
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberT-3585
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: