Healthcare Provider Details

I. General information

NPI: 1063005874
Provider Name (Legal Business Name): NAKESIA ELLIS MSN, PMHNP-BC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/12/2021
Last Update Date: 09/09/2022
Certification Date: 09/09/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2969 CURRAN DR N
JACKSON MS
39216-4121
US

IV. Provider business mailing address

2969 CURRAN DR N
JACKSON MS
39216-4121
US

V. Phone/Fax

Practice location:
  • Phone: 601-200-3100
  • Fax: 601-200-8846
Mailing address:
  • Phone: 601-200-3100
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number904456
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: