Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 363LP2300X | Nurse Practitioner - Primary Care | 865754 | MS |
NPI | 1083246474 |
---|---|
Provider Name | Jennifer Ross Goodwin |
First Address | Hattiesburg, MS 39402-8713 |
Second Address | Hattiesburg, MS 39402-8713 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 04/02/2020 |
Last Update Date | 03/11/2021 |