Provider Demographics
NPI:1255334652
Name:HALLORAN, JENNIFER DAUGHERTY (MD)
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:DAUGHERTY
Last Name:HALLORAN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:100 E DUNE ST
Mailing Address - Street 2:
Mailing Address - City:NAGS HEAD
Mailing Address - State:NC
Mailing Address - Zip Code:27959-8848
Mailing Address - Country:US
Mailing Address - Phone:252-449-5200
Mailing Address - Fax:252-449-5205
Practice Address - Street 1:100 E DUNE ST
Practice Address - Street 2:
Practice Address - City:NAGS HEAD
Practice Address - State:NC
Practice Address - Zip Code:27959-8848
Practice Address - Country:US
Practice Address - Phone:252-449-5200
Practice Address - Fax:252-449-5205
Is Sole Proprietor?:No
Enumeration Date:2005-05-31
Last Update Date:2014-05-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC200300986207R00000X, 208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC135U7Medicaid
NC2025100AMedicare PIN
I12727Medicare UPIN