1194946970 NPI number — JENNIFER K JUSTICE CRNA

Table of content: JENNIFER K JUSTICE CRNA (NPI 1194946970)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1194946970 NPI number — JENNIFER K JUSTICE CRNA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
JUSTICE
Provider First Name:
JENNIFER
Provider Middle Name:
K
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
CRNA
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
KIRKLAND
Provider Other First Name:
JENNIFER
Provider Other Middle Name:
J
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
CRNA
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1194946970
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
05/07/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 627
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
AUBURN
Provider Business Mailing Address State Name:
AL
Provider Business Mailing Address Postal Code:
36831-0627
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
334-528-2499
Provider Business Mailing Address Fax Number:
334-528-2499

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2000 PEPPERELL PKWY
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
OPELIKA
Provider Business Practice Location Address State Name:
AL
Provider Business Practice Location Address Postal Code:
36801-5452
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
334-528-2499
Provider Business Practice Location Address Fax Number:
334-528-2497
Provider Enumeration Date:
05/01/2007

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 163W00000X , with the licence number:  1-087156 , registered in the state of AL ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 367500000X , with the licence number: 1-087156 , registered in the state of AL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 102382 1801867338 , issued by the state of ( AL ) . This identifiers is of the category "MEDICAID".
  • Identifier: 344343 . This is a "WELLCARE CMO - MCCG" identifier , issued by the state of ( GA ) . This identifiers is of the category "OTHER".
  • Identifier: 671345126B , issued by the state of ( AL ) . This identifiers is of the category "MEDICAID".
  • Identifier: 51591711 . This is a "BCBS" identifier , issued by the state of ( AL ) . This identifiers is of the category "OTHER".
  • Identifier: 671345126A . This is a "PEACHSTATE CMO - MCCG" identifier , issued by the state of ( GA ) . This identifiers is of the category "OTHER".
  • Identifier: 671345126A , issued by the state of ( GA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 430080316 . This is a "RAILROAD MCR - MCCG" identifier , issued by the state of ( GA ) . This identifiers is of the category "OTHER".




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