Provider Demographics
NPI:1609213669
Name:PERRY, JENNIFER THREATT (MD)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:THREATT
Last Name:PERRY
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:JENNIFER
Other - Middle Name:ELAINE
Other - Last Name:THREATT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:1726 METROMEDICAL DR
Mailing Address - Street 2:
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28304-3861
Mailing Address - Country:US
Mailing Address - Phone:910-484-2284
Mailing Address - Fax:910-484-1673
Practice Address - Street 1:1 HOPPIN ST
Practice Address - Street 2:SUITE 200
Practice Address - City:PROVIDENCE
Practice Address - State:RI
Practice Address - Zip Code:02903-4923
Practice Address - Country:US
Practice Address - Phone:401-444-5509
Practice Address - Fax:401-444-6763
Is Sole Proprietor?:Yes
Enumeration Date:2013-05-31
Last Update Date:2017-06-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RILP02915207R00000X, 207W00000X
NC2017-00053207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No207W00000XAllopathic & Osteopathic PhysiciansOphthalmology