Healthcare Provider Details

I. General information

NPI: 1790019354
Provider Name (Legal Business Name): JENNIFER BROOKE EDWARDS FNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/29/2009
Last Update Date: 07/22/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

136 MARION AVE
MCCOMB MS
39648-3620
US

IV. Provider business mailing address

136 MARION AVE
MCCOMB MS
39648-3620
US

V. Phone/Fax

Practice location:
  • Phone: 601-684-3210
  • Fax: 601-684-3319
Mailing address:
  • Phone: 601-684-3210
  • Fax: 601-684-3319

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberR875038
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: