Healthcare Provider Details

I. General information

NPI: 1104281781
Provider Name (Legal Business Name): JESSICA MCDONALD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/23/2015
Last Update Date: 12/23/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7100 HIGHWAY 614
MOSS POINT MS
39562-7395
US

IV. Provider business mailing address

7100 HIGHWAY 614
MOSS POINT MS
39562-7395
US

V. Phone/Fax

Practice location:
  • Phone: 228-588-2888
  • Fax: 228-588-2890
Mailing address:
  • Phone: 228-588-2888
  • Fax: 228-588-2890

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License NumberE-09455
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: