Basic Information
| Provider Information | |||||||||
| NPI: | 1063848638 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | ESTOCK | ||||||||
| FirstName: | JENNIFER | ||||||||
| MiddleName: | G. | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | WHNP-BC, ANP-C | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | CARWILE | ||||||||
| OtherFirstName: | JENNIFER | ||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
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| OtherCredential: | WHNP-BC, ANP-C | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 499 GLOSTER CREEK VLG | ||||||||
| Address2: | SUITE D-1 | ||||||||
| City: | TUPELO | ||||||||
| State: | MS | ||||||||
| PostalCode: | 388014600 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6626908007 | ||||||||
| FaxNumber: | 6628424653 | ||||||||
| Practice Location | |||||||||
| Address1: | 499 GLOSTER CREEK VLG | ||||||||
| Address2: | SUITE D-1 | ||||||||
| City: | TUPELO | ||||||||
| State: | MS | ||||||||
| PostalCode: | 388014600 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6626908007 | ||||||||
| FaxNumber: | 6628424653 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/16/2013 | ||||||||
| LastUpdateDate: | 11/25/2014 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363L00000X | R861901 | MS | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |
ID Information
| ID | Type | State | Issuer | Description | 09987864 | 05 | MS | MEDICAID |