Provider Demographics
NPI:1336246289
Name:JAGGERS, FREDENA LUCAS (CRNA)
Entity type:Individual
Prefix:
First Name:FREDENA
Middle Name:LUCAS
Last Name:JAGGERS
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:128 PEACHTREE LN STE B
Mailing Address - Street 2:
Mailing Address - City:ADVANCE
Mailing Address - State:NC
Mailing Address - Zip Code:27006-6783
Mailing Address - Country:US
Mailing Address - Phone:336-624-1648
Mailing Address - Fax:
Practice Address - Street 1:2170 MIDLAND RD
Practice Address - Street 2:
Practice Address - City:SOUTHERN PINES
Practice Address - State:NC
Practice Address - Zip Code:28387-2927
Practice Address - Country:US
Practice Address - Phone:910-295-1221
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-09-20
Last Update Date:2024-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC004545367500000X
TX1047033367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC430056454OtherHRH RR CRNA
NC8051710OtherMEDICAID CRNA PRO.
NC170062OtherLICENSE NUMBER
NC8000180Medicaid
NC8000315Medicaid
NC430079566OtherSCH RR CRNA
NC430079566OtherSCH RR CRNA
NC2618115AMedicare ID - Type UnspecifiedSWAIN CRNA