Healthcare Provider Details

I. General information

NPI: 1588334924
Provider Name (Legal Business Name): JENNIFER KISNER APRN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/16/2021
Last Update Date: 04/26/2026
Certification Date: 04/26/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

680 HIGHWAY 51 STE L
RIDGELAND MS
39157-2103
US

IV. Provider business mailing address

680 HIGHWAY 51 STE L
RIDGELAND MS
39157-2103
US

V. Phone/Fax

Practice location:
  • Phone: 228-669-8823
  • Fax:
Mailing address:
  • Phone: 228-669-8823
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number904794
License Number StateMS
# 2
Primary TaxonomyN
Taxonomy Code363LA2100X
TaxonomyAcute Care Nurse Practitioner
License Number904794
License Number StateMS
# 3
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number904794
License Number StateMS
# 4
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number904794
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: