Provider Demographics
NPI:1376055004
Name:HAWTHORNE, JENNY VIVIAN
Entity type:Individual
Prefix:MRS
First Name:JENNY
Middle Name:VIVIAN
Last Name:HAWTHORNE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8600 MEXICO RD
Mailing Address - Street 2:
Mailing Address - City:O FALLON
Mailing Address - State:MO
Mailing Address - Zip Code:63366-7507
Mailing Address - Country:US
Mailing Address - Phone:636-202-0721
Mailing Address - Fax:
Practice Address - Street 1:8600 MEXICO RD
Practice Address - Street 2:
Practice Address - City:O FALLON
Practice Address - State:MO
Practice Address - Zip Code:63366-7507
Practice Address - Country:US
Practice Address - Phone:636-202-0721
Practice Address - Fax:636-600-5041
Is Sole Proprietor?:No
Enumeration Date:2017-11-03
Last Update Date:2024-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2013031244163W00000X
MO20180009355363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163W00000XNursing Service ProvidersRegistered Nurse