1609198753 NPI number — MRS. SHERRY BULLARD JOBE RN, MSN, ACNP-C

Table of content: MRS. SHERRY BULLARD JOBE RN, MSN, ACNP-C (NPI 1609198753)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1609198753 NPI number — MRS. SHERRY BULLARD JOBE RN, MSN, ACNP-C

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
JOBE
Provider First Name:
SHERRY
Provider Middle Name:
BULLARD
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
RN, MSN, ACNP-C
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
WILSON
Provider Other First Name:
SHERRY
Provider Other Middle Name:
BULLARD
Provider Other Name Prefix Text:
MRS.
Provider Other Name Suffix Text:
Provider Other Credential Text:
RN, MSN, ACNP-BC
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1609198753
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
09/03/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
100 NORMAN RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CORINTH
Provider Business Mailing Address State Name:
MS
Provider Business Mailing Address Postal Code:
38834-9372
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
662-284-8566
Provider Business Mailing Address Fax Number:
662-594-8366

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2668 S HARPER RD STE 1
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CORINTH
Provider Business Practice Location Address State Name:
MS
Provider Business Practice Location Address Postal Code:
38834-6770
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
662-287-7138
Provider Business Practice Location Address Fax Number:
662-287-7157
Provider Enumeration Date:
02/17/2010

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: 363LA2200X , with the licence number:  R701122 , registered in the state of MS ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 1609198753 , issued by the state of ( MS ) . This identifiers is of the category "MEDICAID".




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