Basic Information
| Provider Information | |||||||||
| NPI: | 1063515807 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MOSES | ||||||||
| FirstName: | JENNIFER | ||||||||
| MiddleName: | SHEA | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1020 RIVER OAKS DR | ||||||||
| Address2: | STE 310 | ||||||||
| City: | FLOWOOD | ||||||||
| State: | MS | ||||||||
| PostalCode: | 392329512 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6019325006 | ||||||||
| FaxNumber: | 6019324548 | ||||||||
| Practice Location | |||||||||
| Address1: | 1020 RIVER OAKS DR STE 310 | ||||||||
| Address2: | |||||||||
| City: | JACKSON | ||||||||
| State: | MS | ||||||||
| PostalCode: | 392329512 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6019325006 | ||||||||
| FaxNumber: | 6019324548 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/07/2006 | ||||||||
| LastUpdateDate: | 12/04/2018 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207V00000X | 17261 | MS | Y | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology |
ID Information
| ID | Type | State | Issuer | Description | 05650842 | 05 | MS | MEDICAID |