Basic Information
| Provider Information | |||||||||
| NPI: | 1194188722 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | DOUGLAS | ||||||||
| FirstName: | JESSICA | ||||||||
| MiddleName: | LYNN | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 149 DRINKWATER RD | ||||||||
| Address2: | |||||||||
| City: | BAY ST LOUIS | ||||||||
| State: | MS | ||||||||
| PostalCode: | 395201658 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2284678600 | ||||||||
| FaxNumber: | 2283951225 | ||||||||
| Practice Location | |||||||||
| Address1: | 149 DRINKWATER RD | ||||||||
| Address2: | |||||||||
| City: | BAY ST LOUIS | ||||||||
| State: | MS | ||||||||
| PostalCode: | 395201658 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2284678600 | ||||||||
| FaxNumber: | 2283951225 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/31/2016 | ||||||||
| LastUpdateDate: | 07/19/2019 | ||||||||
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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 | 207Q00000X | 26862 | MS | Y | Allopathic & Osteopathic Physicians | Family Medicine |
No ID Information.