Provider Demographics
NPI:1649075441
Name:CROCKETT, JENNIFER NICOLE (NP)
Entity type:Individual
Prefix:MRS
First Name:JENNIFER
Middle Name:NICOLE
Last Name:CROCKETT
Suffix:
Gender:
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1460 YAKIMA RD
Mailing Address - Street 2:
Mailing Address - City:QUINTON
Mailing Address - State:VA
Mailing Address - Zip Code:23141-1935
Mailing Address - Country:US
Mailing Address - Phone:804-814-7814
Mailing Address - Fax:
Practice Address - Street 1:1460 YAKIMA RD
Practice Address - Street 2:
Practice Address - City:QUINTON
Practice Address - State:VA
Practice Address - Zip Code:23141-1935
Practice Address - Country:US
Practice Address - Phone:804-814-7814
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-02-17
Last Update Date:2025-02-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0024192617363LA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care