Provider Demographics
NPI:1528010808
Name:MYATT, JENNIFER H (MD)
Entity Type:Individual
Prefix:DR
First Name:JENNIFER
Middle Name:H
Last Name:MYATT
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 18563
Mailing Address - Street 2:
Mailing Address - City:RALEIGH
Mailing Address - State:NC
Mailing Address - Zip Code:27619-8563
Mailing Address - Country:US
Mailing Address - Phone:919-781-9979
Mailing Address - Fax:919-781-0124
Practice Address - Street 1:3200 BLUE RIDGE RD
Practice Address - Street 2:STE 210
Practice Address - City:RALEIGH
Practice Address - State:NC
Practice Address - Zip Code:27612-8008
Practice Address - Country:US
Practice Address - Phone:919-781-9979
Practice Address - Fax:919-781-0124
Is Sole Proprietor?:No
Enumeration Date:2006-05-16
Last Update Date:2021-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC9500931207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC8941148Medicaid
NC8941148Medicaid
NC2218407AMedicare ID - Type Unspecified
NC2075081Medicare PIN