1013567445 NPI number — MRS. JESSICA WATSON LOTT AGACNP-BC

Table of content: MRS. JESSICA WATSON LOTT AGACNP-BC (NPI 1013567445)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1013567445 NPI number — MRS. JESSICA WATSON LOTT AGACNP-BC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
LOTT
Provider First Name:
JESSICA
Provider Middle Name:
WATSON
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
AGACNP-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:
1013567445
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
06/05/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
415 S 28TH AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
HATTIESBURG
Provider Business Mailing Address State Name:
MS
Provider Business Mailing Address Postal Code:
39401-7246
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
601-268-5800
Provider Business Mailing Address Fax Number:
601-579-5240

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
404 S 13TH AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LAUREL
Provider Business Practice Location Address State Name:
MS
Provider Business Practice Location Address Postal Code:
39440-4345
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
601-425-5544
Provider Business Practice Location Address Fax Number:
601-425-5525
Provider Enumeration Date:
09/17/2019

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: 363L00000X , with the licence number:  903432 , registered in the state of MS ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 363LA2100X , with the licence number: 903432 , 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: 09482003 , issued by the state of ( MS ) . This identifiers is of the category "MEDICAID".




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