Provider Demographics
NPI:1104834860
Name:SIDDLE, JENNIFER DUCKETT (MD)
Entity Type:Individual
Prefix:DR
First Name:JENNIFER
Middle Name:DUCKETT
Last Name:SIDDLE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:DR
Other - First Name:JENNIFER
Other - Middle Name:DEON
Other - Last Name:DUCKETT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:1400 CRESCENT GRN
Mailing Address - Street 2:SUITE 120
Mailing Address - City:CARY
Mailing Address - State:NC
Mailing Address - Zip Code:27518-8118
Mailing Address - Country:US
Mailing Address - Phone:910-295-6007
Mailing Address - Fax:910-215-0179
Practice Address - Street 1:1400 CRESCENT GRN
Practice Address - Street 2:SUITE 120
Practice Address - City:CARY
Practice Address - State:NC
Practice Address - Zip Code:27518-8118
Practice Address - Country:US
Practice Address - Phone:919-972-7700
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-04
Last Update Date:2014-07-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC2005-019042084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC5903844Medicaid
NC5903844Medicaid
NC45536UMedicare UPIN