Provider Demographics
NPI:1205386109
Name:GRANT, JENNIFER CAMPBELL (PA-C)
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:CAMPBELL
Last Name:GRANT
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4080 GRANITE CIR
Mailing Address - Street 2:
Mailing Address - City:INDIAN LAND
Mailing Address - State:SC
Mailing Address - Zip Code:29707-4000
Mailing Address - Country:US
Mailing Address - Phone:561-729-7015
Mailing Address - Fax:
Practice Address - Street 1:2206 PATTERSON AVE SW
Practice Address - Street 2:
Practice Address - City:ROANOKE
Practice Address - State:VA
Practice Address - Zip Code:24016-2524
Practice Address - Country:US
Practice Address - Phone:540-906-2739
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-10-04
Last Update Date:2024-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC0010-06799363AM0700X, 363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical