Provider Demographics
NPI:1073371258
Name:NETTLES, JENNEFER JEANETTE
Entity Type:Individual
Prefix:
First Name:JENNEFER
Middle Name:JEANETTE
Last Name:NETTLES
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6917 COLONIAL TER
Mailing Address - Street 2:
Mailing Address - City:MOBILE
Mailing Address - State:AL
Mailing Address - Zip Code:36618-4537
Mailing Address - Country:US
Mailing Address - Phone:251-458-7217
Mailing Address - Fax:
Practice Address - Street 1:6917 COLONIAL TER
Practice Address - Street 2:
Practice Address - City:MOBILE
Practice Address - State:AL
Practice Address - Zip Code:36618-4537
Practice Address - Country:US
Practice Address - Phone:251-458-7217
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-03-12
Last Update Date:2024-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL171W00000X
172A00000X, 376K00000X, 374U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374U00000XNursing Service Related ProvidersHome Health Aide
No171W00000XOther Service ProvidersContractor
No172A00000XOther Service ProvidersDriver
No376K00000XNursing Service Related ProvidersNurse's Aide