Provider Demographics
NPI:1285241265
Name:HALES, JENNIFER ANN (NP-C #F05200177)
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:ANN
Last Name:HALES
Suffix:
Gender:F
Credentials:NP-C #F05200177
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:836 E 65TH ST STE 22
Mailing Address - Street 2:
Mailing Address - City:SAVANNAH
Mailing Address - State:GA
Mailing Address - Zip Code:31405-4493
Mailing Address - Country:US
Mailing Address - Phone:912-414-6034
Mailing Address - Fax:
Practice Address - Street 1:11909 MCAULEY DR STE 1002A
Practice Address - Street 2:
Practice Address - City:SAVANNAH
Practice Address - State:GA
Practice Address - Zip Code:31419-1793
Practice Address - Country:US
Practice Address - Phone:912-354-8331
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-09-24
Last Update Date:2020-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN1960202086S0129X, 363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Single Specialty
No2086S0129XAllopathic & Osteopathic PhysiciansSurgeryVascular SurgeryGroup - Single Specialty