Healthcare Provider Details

I. General information

NPI: 1043713167
Provider Name (Legal Business Name): JENIFER JUSTICE CRNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/15/2018
Last Update Date: 01/13/2025
Certification Date: 01/13/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1911 MISSION 66 STE B
VICKSBURG MS
39180-3762
US

IV. Provider business mailing address

215 KATHERINE DR STE A
FLOWOOD MS
39232-9588
US

V. Phone/Fax

Practice location:
  • Phone: 14-562-5986
  • Fax: 855-830-3484
Mailing address:
  • Phone: 601-665-4162
  • Fax: 888-398-1151

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number903324
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: