Basic Information
| Provider Information | |||||||||
| NPI: | 1386221562 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | POLK | ||||||||
| FirstName: | JESSICA | ||||||||
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| Credential: | CFNP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 79 COPPERS FORD RD | ||||||||
| Address2: | |||||||||
| City: | TYLERTOWN | ||||||||
| State: | MS | ||||||||
| PostalCode: | 396674966 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6013037655 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1318 HARRISON AVE | ||||||||
| Address2: | |||||||||
| City: | MCCOMB | ||||||||
| State: | MS | ||||||||
| PostalCode: | 396482830 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6016842300 | ||||||||
| FaxNumber: | 6016842360 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/25/2021 | ||||||||
| LastUpdateDate: | 05/05/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 05/05/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | 904540 | MS | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
ID Information
| ID | Type | State | Issuer | Description | 07678055 | 05 | MS | MEDICAID |