Provider Demographics
NPI:1689041022
Name:HANSEN, JENNY RIDDLE
Entity Type:Individual
Prefix:
First Name:JENNY
Middle Name:RIDDLE
Last Name:HANSEN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:JENNY
Other - Middle Name:ELIZABETH
Other - Last Name:RIDDLE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:4529 JESSUP GROVE RD
Mailing Address - Street 2:
Mailing Address - City:GREENSBORO
Mailing Address - State:NC
Mailing Address - Zip Code:27410-9407
Mailing Address - Country:US
Mailing Address - Phone:336-605-0190
Mailing Address - Fax:336-605-0930
Practice Address - Street 1:4529 JESSUP GROVE RD
Practice Address - Street 2:
Practice Address - City:GREENSBORO
Practice Address - State:NC
Practice Address - Zip Code:27410-9407
Practice Address - Country:US
Practice Address - Phone:336-605-0190
Practice Address - Fax:336-605-0930
Is Sole Proprietor?:No
Enumeration Date:2015-09-01
Last Update Date:2019-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC5007878363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner