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General NPI Number Information
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NPI Number | 1780497503
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Entity Type | Individual
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Provider Name | JOHN BLAKE ENDRIS FNP-C
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Gender | Male
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Dates
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Enumeration Date | 01/27/2025
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Last Update Date | 01/27/2025
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Provider Practice Location Address
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Address Line | 2 LENOX CT
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City | JACKSON
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State | MS
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Zip | 39211-4145
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Country | US
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Telephone | 601-421-3280
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Fax |
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Provider Business Mailing Address
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Address Line | 383 CLARKDELL RD
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City | CANTON
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State | MS
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Zip | 39046-9465
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Country | US
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Telephone |
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Fax |
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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 | 207Q00000X
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Taxonomy Name | Family Medicine Physician
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License Number | 907149
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License Number State | MS
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Taxonomy #2
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Taxonomy Code | 363LF0000X
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Taxonomy Name | Family Nurse Practitioner
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License Number | 907149
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License Number State | MS
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