Provider Demographics
NPI:1801100037
Name:LEGGETT-HUDSON, JENNIFER ROBIN (NP)
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:ROBIN
Last Name:LEGGETT-HUDSON
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:603 S MAIN ST
Mailing Address - Street 2:
Mailing Address - City:MOUNT OLIVE
Mailing Address - State:MS
Mailing Address - Zip Code:39119-8902
Mailing Address - Country:US
Mailing Address - Phone:601-797-3405
Mailing Address - Fax:601-797-9482
Practice Address - Street 1:603 S MAIN ST
Practice Address - Street 2:
Practice Address - City:MOUNT OLIVE
Practice Address - State:MS
Practice Address - Zip Code:39119-8902
Practice Address - Country:US
Practice Address - Phone:601-797-3405
Practice Address - Fax:601-797-9482
Is Sole Proprietor?:No
Enumeration Date:2010-07-29
Last Update Date:2015-07-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSF0610233363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS07624895Medicaid
MS302I506890OtherMEDICARE PTAN