Basic Information
| Provider Information | |||||||||
| NPI: | 1053991760 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | GAINES | ||||||||
| FirstName: | JENNA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 460 CLEARWATER DR NW | ||||||||
| Address2: | |||||||||
| City: | CONCORD | ||||||||
| State: | NC | ||||||||
| PostalCode: | 280273806 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7046802974 | ||||||||
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| Practice Location | |||||||||
| Address1: | 900 BRANCHVIEW DR NE STE 215 | ||||||||
| Address2: | |||||||||
| City: | CONCORD | ||||||||
| State: | NC | ||||||||
| PostalCode: | 280252239 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7047804271 | ||||||||
| FaxNumber: | 8882616694 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/08/2021 | ||||||||
| LastUpdateDate: | 04/08/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 04/08/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 106S00000X | NC | Y |
No ID Information.