Provider Demographics
NPI:1487731204
Name:O'SULLIVAN, JENNIFER (MD)
Entity type:Individual
Prefix:DR
First Name:JENNIFER
Middle Name:
Last Name:O'SULLIVAN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:297 HIGHWAY 51 STE B
Mailing Address - Street 2:
Mailing Address - City:RIDGELAND
Mailing Address - State:MS
Mailing Address - Zip Code:39157-3423
Mailing Address - Country:US
Mailing Address - Phone:601-707-5381
Mailing Address - Fax:601-707-5382
Practice Address - Street 1:297 HIGHWAY 51 STE B
Practice Address - Street 2:
Practice Address - City:RIDGELAND
Practice Address - State:MS
Practice Address - Zip Code:39157-3423
Practice Address - Country:US
Practice Address - Phone:601-707-5381
Practice Address - Fax:601-707-5382
Is Sole Proprietor?:No
Enumeration Date:2006-11-01
Last Update Date:2011-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS19346208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS03232771Medicaid