Ivyraine Women'S Clinic

Primary specialty

Women's Health Nurse PractitionerTaxonomy code 363LW0102X

Legal business name

IVYRAINE WOMEN'S CLINIC

Practice address

3964 Goodman Rd E Ste 131
Southaven, MS 38672-8762

Phone

(662) 856-8440

NPI assigned

Oct 24, 2021

Organization subpart

No

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name

Jennifer Fredrickson, NPNPI 1689710402

Title

NP

Phone

(662) 856-8440

Specialties & licenses 1

Addresses

Medicare fee-for-service enrollment

Enrolled in MS

Enrollment records 1

These CMS records do not include an NPI. They are shown because their name and street address match this provider’s.

CLIA laboratory certificates

Locations

Practitioners 4

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles.

• Jennifer B Fredrickson, APN

  • Women's Health Nurse Practitioner
  • Southaven, MS
  • NPI 1689710402
  Medicare reassignment NPD Authorized official
• Angela Gail Mitchell, FNP-C

  • Family Nurse Practitioner
  • Southaven, MS
  • NPI 1205521028
  Medicare reassignment NPD
• Elizabeth D. Flynn Heitman, A.P.N.

  • Family Nurse Practitioner
  • Germantown, TN
  • NPI 1811931553

  MS

  Medicare reassignment NPD
• Regina Christy Smith, APN

  • Women's Health Nurse Practitioner
  • Southaven, MS
  • NPI 1366596066
  NPD (past)

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1635033600000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1640736000000",
    "number": "1962166264",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "3964 GOODMAN RD E STE 131",
            "city": "SOUTHAVEN",
            "state": "MS",
            "postal_code": "386728762",
            "telephone_number": "662-856-8440"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "3964 GOODMAN RD E STE 131",
            "city": "SOUTHAVEN",
            "state": "MS",
            "postal_code": "386728762",
            "telephone_number": "662-856-8440"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "IVYRAINE WOMEN'S CLINIC",
        "organizational_subpart": "NO",
        "enumeration_date": "2021-10-24",
        "last_updated": "2021-12-29",
        "certification_date": "2021-12-29",
        "status": "A",
        "authorized_official_last_name": "FREDRICKSON",
        "authorized_official_first_name": "JENNIFER",
        "authorized_official_title_or_position": "NP",
        "authorized_official_telephone_number": "662-856-8440",
        "authorized_official_credential": "NP"
    },
    "taxonomies": [
        {
            "code": "363LW0102X",
            "taxonomy_group": "193400000X SINGLE SPECIALTY  GROUP",
            "desc": "Nurse Practitioner, Women's Health",
            "state": null,
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

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• Renita Monae Isom, M.S. CCC-SLP
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• Amanda Degnan Jackson
• Annie Marie Jackson, LMSW
• Cassandra Lovette Jackson, COUNSELOR
• Holly Jackson, CRNA
• Leigh Jackson, MD

• Women's Health Nurse Practitioner in Southaven, MS
• Providers in Southaven, MS by specialty
• Women's Health Nurse Practitioner in Mississippi

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Dec 29, 2021; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments.
• Medicare Care Compare (CMS): clinician profile, group practices, facility affiliations, MIPS scores and star ratings.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.