Provider Demographics
NPI:1184166068
Name:CHILDRESS, JENNIFER (NP)
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:
Last Name:CHILDRESS
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:306 COLLEGE ST
Mailing Address - Street 2:
Mailing Address - City:WILKESBORO
Mailing Address - State:NC
Mailing Address - Zip Code:28697-2854
Mailing Address - Country:US
Mailing Address - Phone:336-651-7533
Mailing Address - Fax:336-651-7813
Practice Address - Street 1:5229 ROCK CREEK ROAD
Practice Address - Street 2:
Practice Address - City:HAYS
Practice Address - State:NC
Practice Address - Zip Code:28635
Practice Address - Country:US
Practice Address - Phone:336-696-2711
Practice Address - Fax:336-696-2829
Is Sole Proprietor?:No
Enumeration Date:2016-11-09
Last Update Date:2020-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCF1116196363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner