=====================================================
General NPI Number Information
=====================================================
NPI Number | 1013698513
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JEQUETTA SHUREKA ILION MCLAURIN FNP
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/27/2023
-----------------------------------------------------
Last Update Date | 08/02/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3502 W NORTHSIDE DR
-----------------------------------------------------
City | JACKSON
-----------------------------------------------------
State | MS
-----------------------------------------------------
Zip | 39213-4454
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 601-362-5321
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 713 S PEAR ORCHARD RD STE 300
-----------------------------------------------------
City | RIDGELAND
-----------------------------------------------------
State | MS
-----------------------------------------------------
Zip | 39157-4823
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 601-957-6300
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363LF0000X
-----------------------------------------------------
Taxonomy Name | Family Nurse Practitioner
-----------------------------------------------------
License Number | 906074
-----------------------------------------------------
License Number State | MS
-----------------------------------------------------