Healthcare Provider Details

I. General information

NPI: 1720193675
Provider Name (Legal Business Name): JODI M STUBBS NP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/20/2006
Last Update Date: 07/16/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1500 E WOODROW WILSON AVE
JACKSON MS
39216-5116
US

IV. Provider business mailing address

169 GRANTS FERRY CIR
BRANDON MS
39047-8128
US

V. Phone/Fax

Practice location:
  • Phone: 601-362-4471
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LA2100X
TaxonomyAcute Care Nurse Practitioner
License NumberR734417
License Number StateMS
# 2
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberR734417
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: