Healthcare Provider Details

I. General information

NPI: 1811944077
Provider Name (Legal Business Name): JOSELYN C BACON CNM
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/30/2006
Last Update Date: 08/28/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

350 W WOODROW WILSON AVE
JACKSON MS
39213-7681
US

IV. Provider business mailing address

350 WEST WOODROW WILSON BLVD HINDS COUNTY HEALTH DEPARTMENT
JACKSON MS
39215
US

V. Phone/Fax

Practice location:
  • Phone: 601-364-2666
  • Fax: 601-364-2659
Mailing address:
  • Phone: 601-364-2666
  • Fax: 601-364-2659

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License NumberR508381
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: