1689079584 NPI number — JENNIFER NEWSOM HALLFORD NP-C

Table of content: JENNIFER NEWSOM HALLFORD NP-C (NPI 1689079584)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1689079584 NPI number — JENNIFER NEWSOM HALLFORD NP-C

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
HALLFORD
Provider First Name:
JENNIFER
Provider Middle Name:
NEWSOM
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
NP-C
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
NEWSOM
Provider Other First Name:
JENNIFER
Provider Other Middle Name:
LEE
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
NP-C
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1689079584
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/19/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 658
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
GAINESVILLE
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
30503-0658
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
770-718-1122
Provider Business Mailing Address Fax Number:
770-535-7445

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
725 JESSE JEWELL PKWY SE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
GAINESVILLE
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
30501-3834
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
770-535-0191
Provider Business Practice Location Address Fax Number:
770-535-7092
Provider Enumeration Date:
11/04/2014

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: 363LF0000X , with the licence number:  RN192628 , registered in the state of GA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 003153670G , issued by the state of ( GA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 003153670F , issued by the state of ( GA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 003153670E , issued by the state of ( GA ) . This identifiers is of the category "MEDICAID".
  • Identifier: RN192628 . This is a "NP LICENSE NUMBER" identifier , issued by the state of ( GA ) . This identifiers is of the category "OTHER".