Provider Demographics
NPI:1831976992
Name:JERNIGAN, ELIZABETH VIRGINIA (AGACNP)
Entity type:Individual
Prefix:
First Name:ELIZABETH
Middle Name:VIRGINIA
Last Name:JERNIGAN
Suffix:
Gender:F
Credentials:AGACNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:P.O. BOX 845347
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75284-7208
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:6201 HARRY HINES BLVD
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75235-5202
Practice Address - Country:US
Practice Address - Phone:469-291-3363
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-09-12
Last Update Date:2024-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX958599363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner