Provider Demographics
NPI:1720149578
Name:WILLARD, JENNIFER REEVES (PA-C)
Entity Type:Individual
Prefix:MRS
First Name:JENNIFER
Middle Name:REEVES
Last Name:WILLARD
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 14883
Mailing Address - Street 2:
Mailing Address - City:GREENSBORO
Mailing Address - State:NC
Mailing Address - Zip Code:27415-4883
Mailing Address - Country:US
Mailing Address - Phone:336-274-6515
Mailing Address - Fax:336-275-0812
Practice Address - Street 1:301 E WENDOVER AVE STE 200
Practice Address - Street 2:
Practice Address - City:GREENSBORO
Practice Address - State:NC
Practice Address - Zip Code:27401-1232
Practice Address - Country:US
Practice Address - Phone:336-482-2309
Practice Address - Fax:336-268-3157
Is Sole Proprietor?:No
Enumeration Date:2006-12-13
Last Update Date:2021-04-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC102881363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC2752219CMedicare PIN
S93042Medicare UPIN