Healthcare Provider Details

I. General information

NPI: 1083981757
Provider Name (Legal Business Name): BIANCA BULLIE-THOMPSON FNP-C, PMHNP-BC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/24/2011
Last Update Date: 06/04/2025
Certification Date: 06/04/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1500 E WOODROW WILSON
JACKSON MS
39216
US

IV. Provider business mailing address

1500 E WOODROW WILSON
JACKSON MS
39216
US

V. Phone/Fax

Practice location:
  • Phone: 601-362-4471
  • Fax: 601-368-4089
Mailing address:
  • Phone: 601-362-4471
  • Fax: 601-368-4089

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number867841
License Number StateMS
# 2
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number2022153286
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: