Provider Demographics
NPI:1316922339
Name:GRIFFIN, JACKIE TANNER (NP)
Entity type:Individual
Prefix:
First Name:JACKIE
Middle Name:TANNER
Last Name:GRIFFIN
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3803 N ELM ST
Mailing Address - Street 2:
Mailing Address - City:GREENSBORO
Mailing Address - State:NC
Mailing Address - Zip Code:27455-2593
Mailing Address - Country:US
Mailing Address - Phone:336-540-7075
Mailing Address - Fax:888-882-3919
Practice Address - Street 1:3803 N ELM ST
Practice Address - Street 2:
Practice Address - City:GREENSBORO
Practice Address - State:NC
Practice Address - Zip Code:27455-2593
Practice Address - Country:US
Practice Address - Phone:336-540-7075
Practice Address - Fax:888-882-3919
Is Sole Proprietor?:No
Enumeration Date:2005-12-13
Last Update Date:2015-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC900292363LF0000X, 363LP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
2328528OtherUNITED HEALTHCARE
P00312506Medicare PIN
2802992AMedicare PIN