Healthcare Provider Details

I. General information

NPI: 1376415851
Provider Name (Legal Business Name): JILLIAN WALTERS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/23/2025
Last Update Date: 06/19/2026
Certification Date: 06/19/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1391 BROAD AVE
GULFPORT MS
39501-2419
US

IV. Provider business mailing address

311 GIVENS DR
BILOXI MS
39531-3277
US

V. Phone/Fax

Practice location:
  • Phone: 228-863-8868
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number907617
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: