Healthcare Provider Details

I. General information

NPI: 1528980612
Provider Name (Legal Business Name): JESSIE LILLEY VAN ETTEN FNP-BC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/29/2026
Last Update Date: 07/29/2026
Certification Date: 07/12/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6380 CLINTON TINNIN RD
JACKSON MS
39209-9119
US

IV. Provider business mailing address

6380 CLINTON TINNIN RD
JACKSON MS
39209-9119
US

V. Phone/Fax

Practice location:
  • Phone: 601-978-0764
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number908645
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: