Provider Demographics
NPI:1932749561
Name:BREATHITT, JENNIFER (APRN)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:
Last Name:BREATHITT
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4542 W WEDGE DR
Mailing Address - Street 2:
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:AR
Mailing Address - Zip Code:72704-7532
Mailing Address - Country:US
Mailing Address - Phone:479-409-6096
Mailing Address - Fax:
Practice Address - Street 1:4542 W WEDGE DR
Practice Address - Street 2:
Practice Address - City:FAYETTEVILLE
Practice Address - State:AR
Practice Address - Zip Code:72704-7532
Practice Address - Country:US
Practice Address - Phone:479-409-6096
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-01-11
Last Update Date:2020-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARA006218363LA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care