Provider Demographics
NPI:1932954286
Name:SMALL, JENNIFER FUNDERBURK (FNP-C)
Entity Type:Individual
Prefix:MRS
First Name:JENNIFER
Middle Name:FUNDERBURK
Last Name:SMALL
Suffix:
Gender:F
Credentials:FNP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 23321
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10087-4321
Mailing Address - Country:US
Mailing Address - Phone:843-876-1344
Mailing Address - Fax:
Practice Address - Street 1:2021 BRIDGEMILL DR
Practice Address - Street 2:
Practice Address - City:INDIAN LAND
Practice Address - State:SC
Practice Address - Zip Code:29707-9210
Practice Address - Country:US
Practice Address - Phone:803-416-5410
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-04-20
Last Update Date:2024-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC28483363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily