Healthcare Provider Details

I. General information

NPI: 1013698513
Provider Name (Legal Business Name): JEQUETTA SHUREKA ILION MCLAURIN FNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/27/2023
Last Update Date: 08/02/2023
Certification Date: 08/02/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3502 W NORTHSIDE DR
JACKSON MS
39213-4454
US

IV. Provider business mailing address

713 S PEAR ORCHARD RD STE 300
RIDGELAND MS
39157-4823
US

V. Phone/Fax

Practice location:
  • Phone: 601-362-5321
  • Fax:
Mailing address:
  • Phone: 601-957-6300
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number906074
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: