Provider Demographics
NPI:1679170740
Name:LASSITER, JENNIFER (ACNPC-AG)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:
Last Name:LASSITER
Suffix:
Gender:F
Credentials:ACNPC-AG
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 759
Mailing Address - Street 2:
Mailing Address - City:LIZELLA
Mailing Address - State:GA
Mailing Address - Zip Code:31052-0759
Mailing Address - Country:US
Mailing Address - Phone:478-808-2945
Mailing Address - Fax:
Practice Address - Street 1:4116 HOLLEY RD.
Practice Address - Street 2:
Practice Address - City:LIZELLA
Practice Address - State:GA
Practice Address - Zip Code:31052
Practice Address - Country:US
Practice Address - Phone:478-808-2945
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-10-02
Last Update Date:2020-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN164928363LA2100X, 363LG0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute CareGroup - Multi-Specialty
No363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontologyGroup - Multi-Specialty