Healthcare Provider Details

I. General information

NPI: 1053884106
Provider Name (Legal Business Name): JENNIFER ELAINE PICKENS FNP-BC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/10/2019
Last Update Date: 08/18/2023
Certification Date: 08/18/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3001 HIGHWAY 72 W
CORINTH MS
38834-9399
US

IV. Provider business mailing address

3001 HIGHWAY 72 W
CORINTH MS
38834-9399
US

V. Phone/Fax

Practice location:
  • Phone: 662-396-0742
  • Fax:
Mailing address:
  • Phone: 662-396-0742
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163WM0705X
TaxonomyMedical-Surgical Registered Nurse
License Number904684
License Number StateMS
# 2
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number904205
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: