Healthcare Provider Details

I. General information

NPI: 1487967410
Provider Name (Legal Business Name): JENNIFER D GHOLSON MD, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/19/2010
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

804 ROBB ST
SUMMIT MS
39666-8291
US

V. Phone/Fax

Practice location:
  • Phone: 601-276-7665
  • Fax: 601-276-7655
Mailing address:
  • Phone: 601-276-7665
  • Fax: 601-276-7655

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: DR. JENNIFER GHOLSON
Title or Position: OWNER
Credential: MD
Phone: 601-276-7665