Provider Demographics
NPI:1568121077
Name:PINA, JENNIFER LEE
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:LEE
Last Name:PINA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:602 CARDINAL DR
Mailing Address - Street 2:
Mailing Address - City:DUBLIN
Mailing Address - State:GA
Mailing Address - Zip Code:31021-5604
Mailing Address - Country:US
Mailing Address - Phone:478-290-0313
Mailing Address - Fax:
Practice Address - Street 1:602 CARDINAL DR
Practice Address - Street 2:
Practice Address - City:DUBLIN
Practice Address - State:GA
Practice Address - Zip Code:31021-5604
Practice Address - Country:US
Practice Address - Phone:478-290-0313
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-12-12
Last Update Date:2021-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GALPN047515164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse