Basic Information
Provider Information
NPI: 1003008475
EntityType: 1
ReplacementNPI:  
OrganizationName:  
LastName: DAVIS
FirstName: JENNIFER
MiddleName: KAY
NamePrefix:  
NameSuffix:  
Credential: NP
OtherOrganizationName:  
OtherOrganizationType:  
OtherLastName:  
OtherFirstName:  
OtherMiddleName:  
OtherNamePrefix:  
OtherNameSuffix:  
OtherCredential:  
OtherLastNameType:  
Mailing Information
Address1: 901 CONNECTOR 206 N
Address2: SUITE C
City: DOUGLAS
State: GA
PostalCode: 315337150
CountryCode: US
TelephoneNumber: 9123896885
FaxNumber:  
Practice Location
Address1: 1400 PETERSON AVE N
Address2: SUITE C
City: DOUGLAS
State: GA
PostalCode: 315332832
CountryCode: US
TelephoneNumber: 9123844000
FaxNumber: 9123844029
Other Information
ProviderEnumerationDate: 08/09/2007
LastUpdateDate: 01/07/2016
NPIDeactivationReasonCode:  
NPIDeactivationDate:  
NPIReactivationDate:  
ProviderGenderCode: F
AuthorizedOfficialLastName:  
AuthorizedOfficialFirstName:  
AuthorizedOfficialMiddleName:  
AuthorizedOfficialTitleorPosition:  
AuthorizedOfficialTelephone:  
IsSoleProprietor: N
IsOrganizationSubpart:  
ParentOrganizationLBN:  
AuthorizedOfficialNamePrefix:  
AuthorizedOfficialNameSuffix:  
AuthorizedOfficialCredential:  
NPICertificationDate:  

Taxonomy Information
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
363LF0000XRN057110 NPGAY Physician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily

No ID Information.


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