Healthcare Provider Details

I. General information

NPI: 1902656564
Provider Name (Legal Business Name): JACKIE EVETTE BROWN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/26/2024
Last Update Date: 03/26/2024
Certification Date: 03/26/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1161 CHURCH RD W
SOUTHAVEN MS
38671-7144
US

IV. Provider business mailing address

PO BOX 306415
NASHVILLE TN
37230-6415
US

V. Phone/Fax

Practice location:
  • Phone: 662-253-1067
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number906591
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: