Healthcare Provider Details

I. General information

NPI: 1770812810
Provider Name (Legal Business Name): JENNIFER WIMBERLY
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/21/2009
Last Update Date: 12/21/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

344 ARLINGTON AVE
NATCHEZ MS
39120-3551
US

IV. Provider business mailing address

344 ARLINGTON AVE
NATCHEZ MS
39120-3551
US

V. Phone/Fax

Practice location:
  • Phone: 601-443-2344
  • Fax: 601-443-9862
Mailing address:
  • Phone: 601-443-2344
  • Fax: 601-443-9862

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License NumberS3084
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: