Provider Demographics
NPI:1689715146
Name:WARREN, JENNIFER T (NP)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:T
Last Name:WARREN
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:966 LYNWOOD RD
Mailing Address - Street 2:
Mailing Address - City:JESUP
Mailing Address - State:GA
Mailing Address - Zip Code:31545-4303
Mailing Address - Country:US
Mailing Address - Phone:912-586-6846
Mailing Address - Fax:
Practice Address - Street 1:1716 ELLIS ST
Practice Address - Street 2:
Practice Address - City:BRUNSWICK
Practice Address - State:GA
Practice Address - Zip Code:31520-6417
Practice Address - Country:US
Practice Address - Phone:912-262-3236
Practice Address - Fax:912-264-0813
Is Sole Proprietor?:No
Enumeration Date:2007-02-09
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN031979363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA50BBDPZMedicare ID - Type Unspecified