Healthcare Provider Details

I. General information

NPI: 1770407785
Provider Name (Legal Business Name): GESSIKA FENNELL
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/05/2026
Last Update Date: 08/05/2026
Certification Date: 08/05/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 STARR AVE STE K
STARKVILLE MS
39759-4032
US

IV. Provider business mailing address

18081 OLD HIGHWAY 25 N
FULTON MS
38843-8502
US

V. Phone/Fax

Practice location:
  • Phone: 662-340-5947
  • Fax:
Mailing address:
  • Phone: 662-873-1266
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberM11700
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: