Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 363L00000X | Nurse Practitioner | 901418 | MS |
NPI | 1003281916 |
---|---|
Provider Name | Jennifer Nichols Foreman |
First Address | Jackson, MS 39216-4500 |
Second Address | Jackson, MS 39216-4500 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 02/12/2015 |
Last Update Date | 24/05/2016 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
01604356 | (05) | MS |