Healthcare Provider Details

I. General information

NPI: 1003281916
Provider Name (Legal Business Name): JENNIFER NICHOLS FOREMAN A-GNP-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/02/2015
Last Update Date: 05/24/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2500 N STATE ST
JACKSON MS
39216-4500
US

IV. Provider business mailing address

2500 NORTH STATE STREET JMM ROOM 2525
JACKSON MS
39216-4500
US

V. Phone/Fax

Practice location:
  • Phone: 601-984-5657
  • Fax:
Mailing address:
  • Phone: 601-984-6426
  • Fax: 601-984-6439

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number901418
License Number StateMS
# 2
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number882741
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: