Healthcare Provider Details

I. General information

NPI: 1972048304
Provider Name (Legal Business Name): JENNIFER W PATE NP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: JENNIFER W HOUSTON

II. Dates (important events)

Enumeration Date: 12/20/2016
Last Update Date: 11/27/2020
Certification Date: 11/27/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2506 LAKELAND DR STE 300
FLOWOOD MS
39232-7640
US

IV. Provider business mailing address

2506 LAKELAND DR STE 300
FLOWOOD MS
39232-7640
US

V. Phone/Fax

Practice location:
  • Phone: 601-326-2599
  • Fax: 601-933-0852
Mailing address:
  • Phone: 601-326-2599
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number901879
License Number StateMS
# 2
Primary TaxonomyN
Taxonomy Code363LA2100X
TaxonomyAcute Care Nurse Practitioner
License Number901879
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: