Healthcare Provider Details

I. General information

NPI: 1295125813
Provider Name (Legal Business Name): JENNIFER EASLEY CPNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/03/2015
Last Update Date: 08/29/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1860 CHADWICK DR SUITE 205
JACKSON MS
39204-3463
US

IV. Provider business mailing address

1860 CHADWICK DR SUITE 205
JACKSON MS
39204-3463
US

V. Phone/Fax

Practice location:
  • Phone: 601-376-2857
  • Fax:
Mailing address:
  • Phone: 601-376-2857
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0200X
TaxonomyPediatric Nurse Practitioner
License NumberR869311
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: