Provider Demographics
NPI:1295219939
Name:DOROUGH, JENNIFER (NP)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:
Last Name:DOROUGH
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4806 GUERRY DR
Mailing Address - Street 2:
Mailing Address - City:MACON
Mailing Address - State:GA
Mailing Address - Zip Code:31210-4104
Mailing Address - Country:US
Mailing Address - Phone:478-320-3480
Mailing Address - Fax:
Practice Address - Street 1:400 CHARTER BLVD
Practice Address - Street 2:
Practice Address - City:MACON
Practice Address - State:GA
Practice Address - Zip Code:31210-4831
Practice Address - Country:US
Practice Address - Phone:478-757-8200
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-09-19
Last Update Date:2018-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN200221363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
GARN200221OtherADVANCED PRACTICE NP