Healthcare Provider Details

I. General information

NPI: 1457854168
Provider Name (Legal Business Name): JESSICA D BUSH NP-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/09/2018
Last Update Date: 12/12/2025
Certification Date: 12/12/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

222 N MAIN ST STE 20
HATTIESBURG MS
39401-2238
US

IV. Provider business mailing address

222 N MAIN ST STE 20
HATTIESBURG MS
39401-2238
US

V. Phone/Fax

Practice location:
  • Phone: 601-336-9119
  • Fax: 888-289-9427
Mailing address:
  • Phone: 601-336-9119
  • Fax: 888-289-9427

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number902556
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: