Provider Demographics
NPI:1922577378
Name:JENKINS, JORDAN LARUE FULCHER (FNP-C)
Entity type:Individual
Prefix:
First Name:JORDAN
Middle Name:LARUE FULCHER
Last Name:JENKINS
Suffix:
Gender:F
Credentials:FNP-C
Other - Prefix:
Other - First Name:JORDAN
Other - Middle Name:LARUE
Other - Last Name:FULCHER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:502 FAWN CV
Mailing Address - Street 2:
Mailing Address - City:CANTON
Mailing Address - State:MS
Mailing Address - Zip Code:39046-9417
Mailing Address - Country:US
Mailing Address - Phone:601-919-5150
Mailing Address - Fax:888-240-6288
Practice Address - Street 1:111 KELLY BLVD
Practice Address - Street 2:
Practice Address - City:MADISON
Practice Address - State:MS
Practice Address - Zip Code:39110-1206
Practice Address - Country:US
Practice Address - Phone:601-898-6080
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-11-15
Last Update Date:2024-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS903027363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily