Provider Demographics
NPI:1619538568
Name:KLEEAN, JENNIFER CRYSTAL
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:CRYSTAL
Last Name:KLEEAN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:JENNIFER
Other - Middle Name:CRYSTAL
Other - Last Name:ROSDHAL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:NP
Mailing Address - Street 1:PO BOX 60447
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28260-0447
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1351 WESTGATE CENTER DR
Practice Address - Street 2:
Practice Address - City:WINSTON SALEM
Practice Address - State:NC
Practice Address - Zip Code:27103-2934
Practice Address - Country:US
Practice Address - Phone:336-718-7777
Practice Address - Fax:336-718-7744
Is Sole Proprietor?:No
Enumeration Date:2019-06-21
Last Update Date:2021-12-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC5011919363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner