Provider Demographics
NPI:1396132171
Name:JERNIGAN, JAMES DAVID JR
Entity type:Individual
Prefix:
First Name:JAMES
Middle Name:DAVID
Last Name:JERNIGAN
Suffix:JR
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3120 N OAK STREET EXT STE C
Mailing Address - Street 2:
Mailing Address - City:VALDOSTA
Mailing Address - State:GA
Mailing Address - Zip Code:31602-5910
Mailing Address - Country:US
Mailing Address - Phone:229-896-4559
Mailing Address - Fax:
Practice Address - Street 1:3120 N OAK STREET EXT STE C
Practice Address - Street 2:
Practice Address - City:VALDOSTA
Practice Address - State:GA
Practice Address - Zip Code:31602-5910
Practice Address - Country:US
Practice Address - Phone:229-896-4559
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-04-20
Last Update Date:2015-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA1388106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA1388Other1388