Healthcare Provider Details

I. General information

NPI: 1629808613
Provider Name (Legal Business Name): KEWANZA R YOUNG FNP-BC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/05/2024
Last Update Date: 08/08/2024
Certification Date: 08/08/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1850 CHADWICK DR
JACKSON MS
39204-3404
US

IV. Provider business mailing address

1850 CHADWICK DR
JACKSON MS
39204-3404
US

V. Phone/Fax

Practice location:
  • Phone: 601-376-1000
  • Fax:
Mailing address:
  • Phone: 601-376-1000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LW0102X
TaxonomyWomen's Health Nurse Practitioner
License Number909140
License Number StateMS
# 2
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number909140
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: