Provider Demographics
NPI:1497160360
Name:JENNEWEIN, NP-C, LLC
Entity Type:Organization
Organization Name:JENNEWEIN, NP-C, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:FAMILY NURSE PRACTITIONER
Authorized Official - Prefix:
Authorized Official - First Name:CHERRI
Authorized Official - Middle Name:
Authorized Official - Last Name:JENNEWEIN
Authorized Official - Suffix:
Authorized Official - Credentials:ARNP, NP-C
Authorized Official - Phone:850-240-9023
Mailing Address - Street 1:722 RODNEY AVE
Mailing Address - Street 2:
Mailing Address - City:FORT WALTON BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32547
Mailing Address - Country:US
Mailing Address - Phone:850-240-9023
Mailing Address - Fax:
Practice Address - Street 1:40 WASHINGTON STREET
Practice Address - Street 2:
Practice Address - City:FREEPORT
Practice Address - State:FL
Practice Address - Zip Code:32439
Practice Address - Country:US
Practice Address - Phone:850-240-9023
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-06-30
Last Update Date:2014-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL9233360302R00000X, 363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Single Specialty
No302R00000XManaged Care OrganizationsHealth Maintenance Organization
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL003390100Medicaid
FL003390100Medicaid