Provider Demographics
NPI:1013147503
Name:SLADE, JENNIFER JOHNSON (CPNP-PC)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:JOHNSON
Last Name:SLADE
Suffix:
Gender:F
Credentials:CPNP-PC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3888 NORTHSIDE DR
Mailing Address - Street 2:
Mailing Address - City:MACON
Mailing Address - State:GA
Mailing Address - Zip Code:31210-2417
Mailing Address - Country:US
Mailing Address - Phone:478-477-4044
Mailing Address - Fax:478-477-7076
Practice Address - Street 1:3888 NORTHSIDE DR
Practice Address - Street 2:
Practice Address - City:MACON
Practice Address - State:GA
Practice Address - Zip Code:31210-2417
Practice Address - Country:US
Practice Address - Phone:478-477-4044
Practice Address - Fax:478-477-7076
Is Sole Proprietor?:No
Enumeration Date:2009-07-20
Last Update Date:2009-07-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN117428 NP363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics