1255965919 NPI number — JENNIFER ETHEL SIZEMORE MSN, RN, PMHNP-BC

Table of content: JENNIFER ETHEL SIZEMORE MSN, RN, PMHNP-BC (NPI 1255965919)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1255965919 NPI number — JENNIFER ETHEL SIZEMORE MSN, RN, PMHNP-BC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
SIZEMORE
Provider First Name:
JENNIFER
Provider Middle Name:
ETHEL
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MSN, RN, PMHNP-BC
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1255965919
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
04/30/2025
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
90 SOUTHERN OAK DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
DOTHAN
Provider Business Mailing Address State Name:
AL
Provider Business Mailing Address Postal Code:
36301-7643
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
850-658-2569
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4296 5TH AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MARIANNA
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
32446-2173
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
850-693-4171
Provider Business Practice Location Address Fax Number:
850-693-4171
Provider Enumeration Date:
03/02/2020

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 363LP0808X , with the licence number:  1-179211 , registered in the state of AL ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 363LP0808X , with the licence number: APRN11008217 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 107359500 . This is a "Florida Medicaid Provider ID" identifier , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".




Copyright © 2007-2025 www.npivalidator.com