Healthcare Provider Details

I. General information

NPI: 1083246474
Provider Name (Legal Business Name): JENNIFER ROSS GOODWIN PNP-PC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/04/2020
Last Update Date: 03/25/2025
Certification Date: 03/25/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

102 MEDICAL PARK
HATTIESBURG MS
39401-9080
US

IV. Provider business mailing address

415 S 28TH AVE
HATTIESBURG MS
39401-7246
US

V. Phone/Fax

Practice location:
  • Phone: 601-261-5159
  • Fax:
Mailing address:
  • Phone: 601-261-5159
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number864754
License Number StateMS
# 2
Primary TaxonomyN
Taxonomy Code363LP0200X
TaxonomyPediatric Nurse Practitioner
License Number865754
License Number StateMS
# 3
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number865754
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: