Provider Demographics
NPI:1629499504
Name:UPCRAFT, JENNIFER
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:
Last Name:UPCRAFT
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 1:10990 BLACKTAIL LOOP
Mailing Address - Street 2:
Mailing Address - City:PENSACOLA
Mailing Address - State:FL
Mailing Address - Zip Code:32526-4578
Mailing Address - Country:US
Mailing Address - Phone:618-559-7363
Mailing Address - Fax:448-400-4235
Practice Address - Street 1:10990 BLACKTAIL LOOP
Practice Address - Street 2:
Practice Address - City:PENSACOLA
Practice Address - State:FL
Practice Address - Zip Code:32526-4578
Practice Address - Country:US
Practice Address - Phone:618-559-7363
Practice Address - Fax:448-400-4235
Is Sole Proprietor?:No
Enumeration Date:2013-12-19
Last Update Date:2023-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR202005777NP-PP363LP0808X
FLARNP9396651363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
IB598ZMedicare PIN