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General NPI Number Information
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NPI Number | 1568473270
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Entity Type | Individual
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Provider Name | JACKIE EUGENE BRISTER F.N.P.
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Gender | Male
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Dates
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Enumeration Date | 08/10/2006
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Last Update Date | 03/12/2008
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Provider Practice Location Address
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Address Line | 1017 DELAWARE AVE
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City | MCCOMB
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State | MS
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Zip | 39648-3827
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Country | US
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Telephone | 601-250-1122
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Fax | 601-250-0290
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Provider Business Mailing Address
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Address Line | PO BOX 1909
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City | MCCOMB
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State | MS
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Zip | 39649-1909
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Country | US
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Telephone | 601-250-1122
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Fax | 601-250-0290
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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 | 363LF0000X
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Taxonomy Name | Family Nurse Practitioner
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License Number | R862702
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License Number State | MS
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