Healthcare Provider Details

I. General information

NPI: 1235480880
Provider Name (Legal Business Name): JESICA DENISE MCKENZIE NP-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/23/2012
Last Update Date: 01/24/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2500 NORTH STATE STREET
JACKSON MS
39216-4500
US

IV. Provider business mailing address

2500 NORTH STATE STREET
JACKSON MS
39216-4500
US

V. Phone/Fax

Practice location:
  • Phone: 601-984-5452
  • Fax: 601-815-3322
Mailing address:
  • Phone: 601-984-5452
  • Fax: 601-815-3322

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License NumberR872871
License Number StateMS
# 2
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number8434518-4405
License Number StateUT
# 3
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number9416834
License Number StateFL
# 4
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number810649
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: