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General NPI Number Information
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NPI Number | 1407682420
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Entity Type | Individual
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Provider Name | JESSICA SULLIVAN CFNP
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Gender | Female
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Dates
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Enumeration Date | 09/09/2024
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Last Update Date | 09/09/2024
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Provider Practice Location Address
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Address Line | 120 MARKET ST
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City | WOODLAND
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State | MS
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Zip | 39776-9104
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Country | US
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Telephone | 662-456-0111
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Fax | 662-456-7335
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Provider Business Mailing Address
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Address Line | 18780 HIGHWAY 46
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City | MANTEE
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State | MS
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Zip | 39751-9514
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Country | US
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Telephone | 662-295-1944
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Fax | 662-456-7335
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 363LP2300X
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Taxonomy Name | Primary Care Nurse Practitioner
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License Number | 906933
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License Number State | MS
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