Healthcare Provider Details

I. General information

NPI: 1235529454
Provider Name (Legal Business Name): JENNIFER CHAMPAGNE NP-C
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/26/2015
Last Update Date: 07/21/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2797 COOPER RD
PICAYUNE MS
39466-2213
US

IV. Provider business mailing address

30030 ROAD 202
CARRIERE MS
39426-9208
US

V. Phone/Fax

Practice location:
  • Phone: 601-799-1616
  • Fax:
Mailing address:
  • Phone: 601-590-1459
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License NumberR871326
License Number StateMS
# 2
Primary TaxonomyN
Taxonomy Code363LG0600X
TaxonomyGerontology Nurse Practitioner
License NumberR871326
License Number StateMS
# 3
Primary TaxonomyN
Taxonomy Code363LP2300X
TaxonomyPrimary Care Nurse Practitioner
License NumberR871326
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: