Provider Demographics
NPI:1538622089
Name:BORUM, JENNIFER GRAVES (AGACNP-BC)
Entity type:Individual
Prefix:MRS
First Name:JENNIFER
Middle Name:GRAVES
Last Name:BORUM
Suffix:
Gender:F
Credentials:AGACNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6 FATHERLAND ROAD
Mailing Address - Street 2:
Mailing Address - City:NATCHEZ
Mailing Address - State:MS
Mailing Address - Zip Code:39120
Mailing Address - Country:US
Mailing Address - Phone:228-861-9030
Mailing Address - Fax:318-339-6388
Practice Address - Street 1:215 KATHERINE DRIVE
Practice Address - Street 2:SUITE A
Practice Address - City:FLOWOOD
Practice Address - State:MS
Practice Address - Zip Code:39232-9588
Practice Address - Country:US
Practice Address - Phone:601-665-4162
Practice Address - Fax:855-830-3484
Is Sole Proprietor?:No
Enumeration Date:2019-04-11
Last Update Date:2023-09-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA204315363LP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary Care