Provider Demographics
NPI:1023012531
Name:CROCKFORD, JENNIFER LYNN (FNP)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:LYNN
Last Name:CROCKFORD
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 7068
Mailing Address - Street 2:
Mailing Address - City:PORTSMOUTH
Mailing Address - State:VA
Mailing Address - Zip Code:23707-0068
Mailing Address - Country:US
Mailing Address - Phone:757-686-3542
Mailing Address - Fax:757-686-0230
Practice Address - Street 1:6161 KEMPSVILLE CLRCLE
Practice Address - Street 2:STE 225
Practice Address - City:NORFOLK
Practice Address - State:VA
Practice Address - Zip Code:23502
Practice Address - Country:US
Practice Address - Phone:757-455-6368
Practice Address - Fax:757-455-6686
Is Sole Proprietor?:No
Enumeration Date:2005-06-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0024 069161363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA77933424Medicaid
VAS71687PMedicare UPIN
VA7793324Medicare ID - Type Unspecified