Provider Demographics
NPI:1861442352
Name:SUMMERVILLE, JEANIE (ARNP, CNM)
Entity Type:Individual
Prefix:
First Name:JEANIE
Middle Name:
Last Name:SUMMERVILLE
Suffix:
Gender:F
Credentials:ARNP, CNM
Other - Prefix:
Other - First Name:JEANIE
Other - Middle Name:SUMMERVILLE
Other - Last Name:GRUENER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:ARNP,CNM
Mailing Address - Street 1:PO BOX 748817
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30374-8817
Mailing Address - Country:US
Mailing Address - Phone:813-286-0033
Mailing Address - Fax:813-282-1806
Practice Address - Street 1:3 SHIRCLIFF WAY STE 200
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32204-4785
Practice Address - Country:US
Practice Address - Phone:904-384-3699
Practice Address - Fax:904-384-8529
Is Sole Proprietor?:No
Enumeration Date:2006-05-12
Last Update Date:2024-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLARNP3005032363LW0102X, 367A00000X, 363LW0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367A00000XPhysician Assistants & Advanced Practice Nursing ProvidersAdvanced Practice Midwife
No363LW0102XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerWomen's Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL002225300Medicaid
FLUG894XMedicare PIN