Provider Demographics
NPI:1912266230
Name:DUCKETT, JENNIFER NICOLE (PA-C)
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:NICOLE
Last Name:DUCKETT
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1114 PROFESSIONAL BLVD
Mailing Address - Street 2:
Mailing Address - City:DALTON
Mailing Address - State:GA
Mailing Address - Zip Code:30720-2588
Mailing Address - Country:US
Mailing Address - Phone:706-278-0138
Mailing Address - Fax:706-278-0347
Practice Address - Street 1:1114 PROFESSIONAL BLVD
Practice Address - Street 2:
Practice Address - City:DALTON
Practice Address - State:GA
Practice Address - Zip Code:30720-2588
Practice Address - Country:US
Practice Address - Phone:706-278-0138
Practice Address - Fax:706-278-0347
Is Sole Proprietor?:No
Enumeration Date:2012-05-07
Last Update Date:2012-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA006427363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant