Provider Demographics
NPI:1336706464
Name:THOMPSON, JENNIFER
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:
Last Name:THOMPSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:JENNIFER
Other - Middle Name:
Other - Last Name:WATSON
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:AG-ACNP
Mailing Address - Street 1:PO BOX 742616
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30374-2616
Mailing Address - Country:US
Mailing Address - Phone:770-219-8420
Mailing Address - Fax:770-219-8440
Practice Address - Street 1:743 SPRING ST NE
Practice Address - Street 2:
Practice Address - City:GAINESVILLE
Practice Address - State:GA
Practice Address - Zip Code:30501
Practice Address - Country:US
Practice Address - Phone:770-219-9000
Practice Address - Fax:770-219-6021
Is Sole Proprietor?:No
Enumeration Date:2019-05-23
Last Update Date:2022-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN215493363L00000X, 363LG0600X, 363LA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontology