Provider Demographics
NPI:1437819513
Name:COLLINS, JERRYL MCGOWAN
Entity type:Individual
Prefix:MS
First Name:JERRYL
Middle Name:MCGOWAN
Last Name:COLLINS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:71 CROSS CREEK RD.
Mailing Address - Street 2:
Mailing Address - City:HATTIEBURG
Mailing Address - State:MS
Mailing Address - Zip Code:39402
Mailing Address - Country:US
Mailing Address - Phone:601-596-2523
Mailing Address - Fax:
Practice Address - Street 1:411 OAK STREET
Practice Address - Street 2:
Practice Address - City:RICHTON
Practice Address - State:MS
Practice Address - Zip Code:39476
Practice Address - Country:US
Practice Address - Phone:601-408-0719
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-12-30
Last Update Date:2021-12-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS904792363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health