Provider Demographics
NPI:1124359021
Name:THIBAULT, JEAN (CRNP, MPH)
Entity Type:Individual
Prefix:MS
First Name:JEAN
Middle Name:
Last Name:THIBAULT
Suffix:
Gender:F
Credentials:CRNP, MPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2995 DREW STREET
Mailing Address - Street 2:EAST BLDG 2ND FLOOR
Mailing Address - City:CLEARWATER
Mailing Address - State:FL
Mailing Address - Zip Code:33759
Mailing Address - Country:US
Mailing Address - Phone:727-281-9390
Mailing Address - Fax:813-635-2613
Practice Address - Street 1:4525 CAMERON VALLEY PARKWAY
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28211-3546
Practice Address - Country:US
Practice Address - Phone:704-302-8310
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-01-18
Last Update Date:2019-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL1-104989363LF0000X
NC5004969363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC7004773Medicaid