Provider Demographics
NPI:1316505373
Name:WOOTEN, JENNIFER LYNN
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:LYNN
Last Name:WOOTEN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:411 STEPHENSON AVE
Mailing Address - Street 2:
Mailing Address - City:SAVANNAH
Mailing Address - State:GA
Mailing Address - Zip Code:31405-5968
Mailing Address - Country:US
Mailing Address - Phone:912-354-7679
Mailing Address - Fax:
Practice Address - Street 1:411 STEPHENSON AVE
Practice Address - Street 2:
Practice Address - City:SAVANNAH
Practice Address - State:GA
Practice Address - Zip Code:31405-5968
Practice Address - Country:US
Practice Address - Phone:912-354-7679
Practice Address - Fax:912-354-4018
Is Sole Proprietor?:Yes
Enumeration Date:2019-06-04
Last Update Date:2020-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA150597363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily