Provider Demographics
NPI:1629776984
Name:DURHAM, JENNIFER (DNP-AGPCNP)
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:
Last Name:DURHAM
Suffix:
Gender:F
Credentials:DNP-AGPCNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:405 THOMPSON ST
Mailing Address - Street 2:
Mailing Address - City:EDEN
Mailing Address - State:NC
Mailing Address - Zip Code:27288-5045
Mailing Address - Country:US
Mailing Address - Phone:336-627-4896
Mailing Address - Fax:
Practice Address - Street 1:158 EXECUTIVE DR
Practice Address - Street 2:
Practice Address - City:DANVILLE
Practice Address - State:VA
Practice Address - Zip Code:24541-4100
Practice Address - Country:US
Practice Address - Phone:434-791-1088
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-02-16
Last Update Date:2025-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC256042163W00000X
VA0024188273363LP2300X, 363LG0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontology
No163W00000XNursing Service ProvidersRegistered Nurse
No363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary Care