Provider Demographics
NPI:1831174028
Name:DR. JERNIGAN AND ASSOCIATES, P.A.
Entity type:Organization
Organization Name:DR. JERNIGAN AND ASSOCIATES, P.A.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:EDWARD
Authorized Official - Middle Name:WILLIAMS
Authorized Official - Last Name:JERNIGAN
Authorized Official - Suffix:JR
Authorized Official - Credentials:DDS
Authorized Official - Phone:252-977-7197
Mailing Address - Street 1:1427 N WESLEYAN BLVD
Mailing Address - Street 2:
Mailing Address - City:ROCKY MOUNT
Mailing Address - State:NC
Mailing Address - Zip Code:27804
Mailing Address - Country:US
Mailing Address - Phone:252-977-7197
Mailing Address - Fax:252-977-6756
Practice Address - Street 1:1427 N WESLEYAN BLVD
Practice Address - Street 2:
Practice Address - City:ROCKY MOUNT
Practice Address - State:NC
Practice Address - Zip Code:27804-1843
Practice Address - Country:US
Practice Address - Phone:252-977-7197
Practice Address - Fax:252-977-7403
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-12-09
Last Update Date:2023-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC51401223G0001X
NC49131223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC5140OtherDR DAVIS DENTAL LICENSE
NC8992091Medicaid
NC4913OtherDR JERNIGAN DENTAL LIC#
NC8994578Medicaid
NCDEA AJ1656290OtherDR JERNIGAN DEA#
NCDEA AD2202454OtherDR. DAVIS DEA #
NCDEA AJ1656290OtherDR JERNIGAN DEA#
NCU41494Medicare UPIN