Provider Demographics
NPI:1437154093
Name:HULL, JENNIFER MARIE (PA-C)
Entity Type:Individual
Prefix:MRS
First Name:JENNIFER
Middle Name:MARIE
Last Name:HULL
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:149 PLANTATION RIDGE DR
Mailing Address - Street 2:SUITE 190
Mailing Address - City:MOORESVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28117-9174
Mailing Address - Country:US
Mailing Address - Phone:704-658-0595
Mailing Address - Fax:704-658-0916
Practice Address - Street 1:6035 FAIRVIEW RD
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28210-3256
Practice Address - Country:US
Practice Address - Phone:704-295-3000
Practice Address - Fax:704-295-3468
Is Sole Proprietor?:No
Enumeration Date:2005-06-20
Last Update Date:2017-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMA051750363A00000X
NC0010-06357363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC19HS5OtherBCBS
NCNCS417AOtherMEDICARE
PA1669926OtherBLUE SHIELD
PAP00170527OtherRR MEDICARE
NCP01848168OtherRAILROAD MEDICARE
SC2601PAMedicaid
PA086751E7CMedicare PIN
SC2601PAMedicaid