Basic Information
| Provider Information | |||||||||
| NPI: | 1821651589 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GAUT | ||||||||
| FirstName: | JENNA | ||||||||
| MiddleName: | L | ||||||||
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| Credential: | CRNP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 850 PETER BRYCE BLVD | ||||||||
| Address2: | |||||||||
| City: | TUSCALOOSA | ||||||||
| State: | AL | ||||||||
| PostalCode: | 354017457 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2053481770 | ||||||||
| FaxNumber: | 2053481772 | ||||||||
| Practice Location | |||||||||
| Address1: | 809 UNIVERSITY BLVD E | ||||||||
| Address2: | |||||||||
| City: | TUSCALOOSA | ||||||||
| State: | AL | ||||||||
| PostalCode: | 354012029 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2057597111 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 04/18/2019 | ||||||||
| LastUpdateDate: | 04/18/2019 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | 1-128666 | AL | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
ID Information
| ID | Type | State | Issuer | Description | 1-128666 | 01 | AL | STATE LICENSE | OTHER |