Provider Demographics
NPI:1750352423
Name:WILLARD, JENNIFER MCDONALD (MD)
Entity type:Individual
Prefix:DR
First Name:JENNIFER
Middle Name:MCDONALD
Last Name:WILLARD
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 602195
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28260-2195
Mailing Address - Country:US
Mailing Address - Phone:919-350-0351
Mailing Address - Fax:919-350-7687
Practice Address - Street 1:1030 SIENA DRIVE
Practice Address - Street 2:
Practice Address - City:RALEIGH
Practice Address - State:NC
Practice Address - Zip Code:27587-2781
Practice Address - Country:US
Practice Address - Phone:919-235-6511
Practice Address - Fax:919-341-3578
Is Sole Proprietor?:No
Enumeration Date:2006-01-30
Last Update Date:2024-10-31
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NC97016572080A0000X, 208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
No2080A0000XAllopathic & Osteopathic PhysiciansPediatricsAdolescent Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC891197NMedicaid
NC1750352423Medicaid