Provider Demographics
NPI:1144784372
Name:ETHERIDGE, JENNIFER SIMPSON
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:SIMPSON
Last Name:ETHERIDGE
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 1:1360 CADUCEUS WAY STE 105
Mailing Address - Street 2:
Mailing Address - City:WATKINSVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30677-7300
Mailing Address - Country:US
Mailing Address - Phone:706-850-3795
Mailing Address - Fax:877-580-1676
Practice Address - Street 1:1360 CADUCEUS WAY STE 105
Practice Address - Street 2:
Practice Address - City:WATKINSVILLE
Practice Address - State:GA
Practice Address - Zip Code:30677-7300
Practice Address - Country:US
Practice Address - Phone:706-850-3795
Practice Address - Fax:877-580-1676
Is Sole Proprietor?:No
Enumeration Date:2019-01-22
Last Update Date:2021-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN222355163W00000X, 363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
No163W00000XNursing Service ProvidersRegistered Nurse