Provider Demographics
NPI:1164940904
Name:LITTLE, JENNIFER C
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:C
Last Name:LITTLE
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 1:23471 FLORA PARKE BLVD
Mailing Address - Street 2:
Mailing Address - City:FERNANDINA BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32034-8172
Mailing Address - Country:US
Mailing Address - Phone:904-321-6332
Mailing Address - Fax:
Practice Address - Street 1:23471 FLORA PARKE BLVD
Practice Address - Street 2:
Practice Address - City:FERNANDINA BEACH
Practice Address - State:FL
Practice Address - Zip Code:32034-8172
Practice Address - Country:US
Practice Address - Phone:904-321-6332
Practice Address - Fax:904-321-6332
Is Sole Proprietor?:Yes
Enumeration Date:2017-08-31
Last Update Date:2017-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL2809942363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Single Specialty