Healthcare Provider Details

I. General information

NPI: 1366991101
Provider Name (Legal Business Name): SHERQUITA JOHNSON-BANKS CFNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/21/2016
Last Update Date: 08/25/2022
Certification Date: 08/25/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3502 W NORTHSIDE DR
JACKSON MS
39213-4454
US

IV. Provider business mailing address

3502 W NORTHSIDE DR
JACKSON MS
39213-4454
US

V. Phone/Fax

Practice location:
  • Phone: 601-362-5321
  • Fax: 601-364-5124
Mailing address:
  • Phone: 601-362-5321
  • Fax: 601-364-5124

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number901775
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: