Healthcare Provider Details

I. General information

NPI: 1790658151
Provider Name (Legal Business Name): JACQUELYN BROOKS FNP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: JACQUELYN PILGREEN

II. Dates (important events)

Enumeration Date: 09/24/2025
Last Update Date: 09/24/2025
Certification Date: 09/23/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

971 LAKELAND DR STE 1052
JACKSON MS
39216-4609
US

IV. Provider business mailing address

971 LAKELAND DR STE 1052
JACKSON MS
39216-4609
US

V. Phone/Fax

Practice location:
  • Phone: 601-981-9503
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number907793
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: