Healthcare Provider Details

I. General information

NPI: 1174588834
Provider Name (Legal Business Name): JENNIFER GHOLSON MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/18/2006
Last Update Date: 06/16/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

804 ROBB ST
SUMMIT MS
39666-8291
US

IV. Provider business mailing address

PO BOX 1268
SUMMIT MS
39666-1268
US

V. Phone/Fax

Practice location:
  • Phone: 601-276-7665
  • Fax:
Mailing address:
  • Phone: 601-276-7665
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number17561
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: