Healthcare Provider Details

I. General information

NPI: 1538455639
Provider Name (Legal Business Name): JESSICA WENTZ RN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/27/2011
Last Update Date: 06/27/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2441A COUNTY ROAD 501
RIPLEY MS
38663-9677
US

IV. Provider business mailing address

PO BOX 839
CORINTH MS
38835-0839
US

V. Phone/Fax

Practice location:
  • Phone: 662-837-8154
  • Fax: 662-837-9462
Mailing address:
  • Phone: 662-286-9883
  • Fax: 662-286-9836

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License NumberR875594
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: