Provider Demographics
NPI:1417412792
Name:THIESSEN, JENNIFER (FNP-C)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:
Last Name:THIESSEN
Suffix:
Gender:F
Credentials:FNP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6345 N CROATAN HWY STE 201
Mailing Address - Street 2:
Mailing Address - City:KITTY HAWK
Mailing Address - State:NC
Mailing Address - Zip Code:27949-3887
Mailing Address - Country:US
Mailing Address - Phone:252-715-4466
Mailing Address - Fax:252-715-4468
Practice Address - Street 1:6345 N CROATAN HWY
Practice Address - Street 2:
Practice Address - City:KITTY HAWK
Practice Address - State:NC
Practice Address - Zip Code:27949-3887
Practice Address - Country:US
Practice Address - Phone:252-715-4466
Practice Address - Fax:252-715-4468
Is Sole Proprietor?:Yes
Enumeration Date:2019-01-31
Last Update Date:2023-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC5012458207QA0401X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207QA0401XAllopathic & Osteopathic PhysiciansFamily MedicineAddiction MedicineGroup - Single Specialty