Provider Demographics
NPI:1720400468
Name:BAUCOM, JENNY BROOKE (PA-C)
Entity Type:Individual
Prefix:
First Name:JENNY
Middle Name:BROOKE
Last Name:BAUCOM
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:104 HUFFMAN MILL RD
Mailing Address - Street 2:
Mailing Address - City:BURLINGTON
Mailing Address - State:NC
Mailing Address - Zip Code:27215-5113
Mailing Address - Country:US
Mailing Address - Phone:336-506-1720
Mailing Address - Fax:
Practice Address - Street 1:104 HUFFMAN MILL RD
Practice Address - Street 2:
Practice Address - City:BURLINGTON
Practice Address - State:NC
Practice Address - Zip Code:27215-5113
Practice Address - Country:US
Practice Address - Phone:336-506-1720
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-01-15
Last Update Date:2023-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC0010-04752363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant