Basic Information
| Provider Information | |||||||||
| NPI: | 1952475642 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | JESSOP | ||||||||
| FirstName: | WILLIE | ||||||||
| MiddleName: | MAE M | ||||||||
| NamePrefix: | MRS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | CFNP | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | MILLER | ||||||||
| OtherFirstName: | WILLIE | ||||||||
| OtherMiddleName: | MAE | ||||||||
| OtherNamePrefix: | |||||||||
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| OtherCredential: | RN | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 6105 KAY BROOK DRIVE | ||||||||
| Address2: | |||||||||
| City: | BYRAM | ||||||||
| State: | MS | ||||||||
| PostalCode: | 392729660 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6013464303 | ||||||||
| FaxNumber: | 6627160689 | ||||||||
| Practice Location | |||||||||
| Address1: | 215 E 5TH STREET | ||||||||
| Address2: | WOOLFOLK SCHOOL-BASED CLINIC GA CARMICHAEL FAMILY HEALT | ||||||||
| City: | YAZOO CITY | ||||||||
| State: | MS | ||||||||
| PostalCode: | 39194 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6627160691 | ||||||||
| FaxNumber: | 6627160689 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/17/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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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 | 363LF0000X | R107300 | MS | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
ID Information
| ID | Type | State | Issuer | Description | 0118259 | 05 | MS | MEDICAID |