Provider Demographics
NPI:1386801900
Name:THOMPSON, JENNIFER SMITH (FNP)
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:SMITH
Last Name:THOMPSON
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1502 W 3RD ST
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:GA
Mailing Address - Zip Code:30233-1979
Mailing Address - Country:US
Mailing Address - Phone:678-774-0430
Mailing Address - Fax:770-775-3410
Practice Address - Street 1:1502 W 3RD ST
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:GA
Practice Address - Zip Code:30233-1979
Practice Address - Country:US
Practice Address - Phone:678-774-0430
Practice Address - Fax:770-775-3410
Is Sole Proprietor?:No
Enumeration Date:2008-05-21
Last Update Date:2015-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN142971363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA235074233AMedicaid