Healthcare Provider Details

I. General information

NPI: 1497380711
Provider Name (Legal Business Name): JANICE JOHNSON TILLMAN FNP-BC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/06/2020
Last Update Date: 06/21/2021
Certification Date: 06/21/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5429 ROBINSON ROAD EXT
JACKSON MS
39204-4138
US

IV. Provider business mailing address

2050 RUSSELL J TILLMAN RD
EDWARDS MS
39066-9101
US

V. Phone/Fax

Practice location:
  • Phone: 601-914-0163
  • Fax: 601-914-0170
Mailing address:
  • Phone: 601-988-3728
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number884780
License Number StateMS
# 2
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number904041
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: