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General NPI Number Information
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NPI Number | 1912904590
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Entity Type | Individual
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Provider Name | JESSE PULLEN PENICO MD
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Gender | Male
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Dates
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Enumeration Date | 06/28/2005
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Last Update Date | 09/22/2020
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Provider Practice Location Address
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Address Line | 1340 BROAD AVE SUITE 300
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City | GULFPORT
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State | MS
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Zip | 39501-2404
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Country | US
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Telephone | 228-575-2700
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Fax | 228-575-2709
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Provider Business Mailing Address
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Address Line | PO BOX 1810
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City | GULFPORT
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State | MS
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Zip | 39502-1810
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Country | US
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Telephone | 228-575-2700
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Fax | 228-575-2710
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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 | 207RI0200X
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Taxonomy Name | Infectious Disease Physician
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License Number | ME72349
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License Number State | FL
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Taxonomy #2
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Taxonomy Code | 207RI0200X
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Taxonomy Name | Infectious Disease Physician
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License Number | 015311
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License Number State | LA
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Taxonomy #3
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Taxonomy Code | 207RI0200X
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Taxonomy Name | Infectious Disease Physician
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License Number | 21358
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License Number State | MS
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