Provider Demographics
NPI:1003192436
Name:JERNIGAN, LAUREN A (PA-C)
Entity Type:Individual
Prefix:
First Name:LAUREN
Middle Name:A
Last Name:JERNIGAN
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10 MARKET SQUARE WAY
Mailing Address - Street 2:SUITE 100
Mailing Address - City:NEWNAN
Mailing Address - State:GA
Mailing Address - Zip Code:30265-6078
Mailing Address - Country:US
Mailing Address - Phone:678-423-5560
Mailing Address - Fax:678-423-5563
Practice Address - Street 1:10 MARKET SQUARE WAY
Practice Address - Street 2:SUITE 100
Practice Address - City:NEWNAN
Practice Address - State:GA
Practice Address - Zip Code:30265
Practice Address - Country:US
Practice Address - Phone:678-423-5560
Practice Address - Fax:678-423-5563
Is Sole Proprietor?:No
Enumeration Date:2011-10-31
Last Update Date:2015-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA006233363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA003119030Medicaid
GA003119030BMedicaid