Provider Demographics
NPI:1306303821
Name:JERNIGAN, ALVIN DWAYNE SR
Entity type:Individual
Prefix:
First Name:ALVIN
Middle Name:DWAYNE
Last Name:JERNIGAN
Suffix:SR
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:386 NE VOSS RD
Mailing Address - Street 2:
Mailing Address - City:LAKE CITY
Mailing Address - State:FL
Mailing Address - Zip Code:32055-1486
Mailing Address - Country:US
Mailing Address - Phone:386-292-3154
Mailing Address - Fax:
Practice Address - Street 1:386 NE VOSS RD
Practice Address - Street 2:
Practice Address - City:LAKE CITY
Practice Address - State:FL
Practice Address - Zip Code:32055-1486
Practice Address - Country:US
Practice Address - Phone:386-292-3154
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-02-21
Last Update Date:2019-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes343900000XTransportation ServicesNon-emergency Medical Transport (VAN)
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL343900000XOtherNON-EMERGENCY TRANSPORT