1063760577 NPI number — MRS. JOLENE CROUCH JERNIGAN FNP

Table of content: MRS. JOLENE CROUCH JERNIGAN FNP (NPI 1063760577)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1063760577 NPI number — MRS. JOLENE CROUCH JERNIGAN FNP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
JERNIGAN
Provider First Name:
JOLENE
Provider Middle Name:
CROUCH
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
FNP
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
JERNIGAN
Provider Other First Name:
JOLENE
Provider Other Middle Name:
C
Provider Other Name Prefix Text:
MRS.
Provider Other Name Suffix Text:
Provider Other Credential Text:
FNP
Provider Other Last Name Type Code:
2

NPI Number Information

NPI Number:
1063760577
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
02/23/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1000 E FIFTH ST
Provider Second Line Business Mailing Address:
EAST CAROLINA UNIVERSITY STUDENT HEALTH SERVICE
Provider Business Mailing Address City Name:
GREENVILLE
Provider Business Mailing Address State Name:
NC
Provider Business Mailing Address Postal Code:
27858-2502
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
252-737-2615
Provider Business Mailing Address Fax Number:
252-328-4007

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1000 E FIFTH ST
Provider Second Line Business Practice Location Address:
EAST CAROLINA UNIVERSITY STUDENT HEALTH SERVICE
Provider Business Practice Location Address City Name:
GREENVILLE
Provider Business Practice Location Address State Name:
NC
Provider Business Practice Location Address Postal Code:
27858-2502
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
252-737-2615
Provider Business Practice Location Address Fax Number:
252-328-4007
Provider Enumeration Date:
08/15/2012

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:  200196 , registered in the state of NC ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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