Healthcare Provider Details

I. General information

NPI: 1518219914
Provider Name (Legal Business Name): GLORIA SIMO JAQUES NP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/09/2012
Last Update Date: 06/18/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2500 N STATE ST DEPARTMENT OF MEDICINE/WOUND CARE GMED
JACKSON MS
39216-4500
US

IV. Provider business mailing address

2500 N STATE ST UNIVERSITY PHYSICIANS
JACKSON MS
39216-4500
US

V. Phone/Fax

Practice location:
  • Phone: 601-984-1000
  • Fax:
Mailing address:
  • Phone: 601-984-1000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LG0600X
TaxonomyGerontology Nurse Practitioner
License NumberR850494
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: