Provider Demographics
NPI:1902382468
Name:JERNIGAN, JILLIAN LEIGH
Entity Type:Individual
Prefix:
First Name:JILLIAN
Middle Name:LEIGH
Last Name:JERNIGAN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6593 OLD RIVER RD
Mailing Address - Street 2:
Mailing Address - City:BAKER
Mailing Address - State:FL
Mailing Address - Zip Code:32531-8142
Mailing Address - Country:US
Mailing Address - Phone:850-305-9733
Mailing Address - Fax:
Practice Address - Street 1:5942 BERRYHILL RD
Practice Address - Street 2:
Practice Address - City:MILTON
Practice Address - State:FL
Practice Address - Zip Code:32570-4009
Practice Address - Country:US
Practice Address - Phone:850-981-3700
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-07-17
Last Update Date:2018-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLARNP9264700367A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367A00000XPhysician Assistants & Advanced Practice Nursing ProvidersAdvanced Practice Midwife