Provider Demographics
NPI:1588551907
Name:JERNIGAN, GEORGE ALTON III
Entity type:Individual
Prefix:
First Name:GEORGE
Middle Name:ALTON
Last Name:JERNIGAN
Suffix:III
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1216 REDCLIFFE LN
Mailing Address - Street 2:
Mailing Address - City:ST AUGUSTINE
Mailing Address - State:FL
Mailing Address - Zip Code:32095-8430
Mailing Address - Country:US
Mailing Address - Phone:910-750-2969
Mailing Address - Fax:
Practice Address - Street 1:1216 REDCLIFFE LN
Practice Address - Street 2:
Practice Address - City:ST AUGUSTINE
Practice Address - State:FL
Practice Address - Zip Code:32095-8430
Practice Address - Country:US
Practice Address - Phone:910-750-2969
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-06-19
Last Update Date:2025-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker