Provider Demographics
NPI:1790793479
Name:PUGH, JENA (CNP)
Entity Type:Individual
Prefix:
First Name:JENA
Middle Name:
Last Name:PUGH
Suffix:
Gender:F
Credentials:CNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:759 OLD NORCROSS RD
Mailing Address - Street 2:
Mailing Address - City:LAWRENCEVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30046-4317
Mailing Address - Country:US
Mailing Address - Phone:404-300-2379
Mailing Address - Fax:404-300-2379
Practice Address - Street 1:759 OLD NORCROSS RD
Practice Address - Street 2:
Practice Address - City:LAWRENCEVILLE
Practice Address - State:GA
Practice Address - Zip Code:30046-4317
Practice Address - Country:US
Practice Address - Phone:404-300-2379
Practice Address - Fax:404-300-2379
Is Sole Proprietor?:No
Enumeration Date:2006-08-04
Last Update Date:2017-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN208906363LW0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LW0102XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerWomen's Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA003128343EMedicaid
GA003128343CMedicaid
OH2669474Medicaid
GA003128343EMedicaid