Provider Demographics
NPI:1356701783
Name:KIDS FIRST PEDIATRIC & ADULT MEDICINE, LLC
Entity type:Organization
Organization Name:KIDS FIRST PEDIATRIC & ADULT MEDICINE, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:FAMILY NURSE PRACTITIONER
Authorized Official - Prefix:
Authorized Official - First Name:TIFFANY
Authorized Official - Middle Name:ROCHELLE
Authorized Official - Last Name:JACKSON
Authorized Official - Suffix:
Authorized Official - Credentials:FNP
Authorized Official - Phone:601-668-8400
Mailing Address - Street 1:PO BOX 495
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:MS
Mailing Address - Zip Code:39205-0495
Mailing Address - Country:US
Mailing Address - Phone:601-668-8400
Mailing Address - Fax:
Practice Address - Street 1:529 LAKE ST STE B
Practice Address - Street 2:
Practice Address - City:HAZLEHURST
Practice Address - State:MS
Practice Address - Zip Code:39083-2226
Practice Address - Country:US
Practice Address - Phone:601-668-8400
Practice Address - Fax:601-623-9246
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-02-26
Last Update Date:2021-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSR881238364SP0200X
364SF0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes364SF0001XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistFamily HealthGroup - Single Specialty
No364SP0200XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistPediatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS=========OtherEIN