Healthcare Provider Details

I. General information

NPI: 1154181295
Provider Name (Legal Business Name): BRANDI JEFFERSON NP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: BRANDI JEFFERSON

II. Dates (important events)

Enumeration Date: 03/19/2024
Last Update Date: 03/19/2024
Certification Date: 03/18/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

30 CIRCLE J DR
LAUREL MS
39440-1980
US

IV. Provider business mailing address

30 CIRCLE J DR
LAUREL MS
39440-1980
US

V. Phone/Fax

Practice location:
  • Phone: 601-425-0092
  • Fax:
Mailing address:
  • Phone: 601-425-0092
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number906437
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: