Provider Demographics
NPI:1609132463
Name:JENNINGS, HEATHER (NP)
Entity Type:Individual
Prefix:
First Name:HEATHER
Middle Name:
Last Name:JENNINGS
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1235 BERKLEY HILLS PASS
Mailing Address - Street 2:
Mailing Address - City:EVANS
Mailing Address - State:GA
Mailing Address - Zip Code:30809-7472
Mailing Address - Country:US
Mailing Address - Phone:706-829-8032
Mailing Address - Fax:
Practice Address - Street 1:1235 BERKLEY HILLS PASS
Practice Address - Street 2:
Practice Address - City:EVANS
Practice Address - State:GA
Practice Address - Zip Code:30809-7472
Practice Address - Country:US
Practice Address - Phone:706-829-8032
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-04-05
Last Update Date:2012-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SCAPRN17768363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily