Healthcare Provider Details

I. General information

NPI: 1972910321
Provider Name (Legal Business Name): JESSICA RICHARDSON FNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/17/2014
Last Update Date: 04/07/2025
Certification Date: 04/07/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

604 S MAIN ST
WATER VALLEY MS
38965-3468
US

IV. Provider business mailing address

604 S MAIN ST
WATER VALLEY MS
38965-3468
US

V. Phone/Fax

Practice location:
  • Phone: 662-473-1311
  • Fax: 662-473-4191
Mailing address:
  • Phone: 662-473-1311
  • Fax: 662-473-4191

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberR881515
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: