Provider Demographics
NPI:1972986842
Name:PELLETIER, JENNIFER LYNN (PA-C, RD, CSSD, CSCS)
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:LYNN
Last Name:PELLETIER
Suffix:
Gender:F
Credentials:PA-C, RD, CSSD, CSCS
Other - Prefix:
Other - First Name:JENNIFER
Other - Middle Name:LYNN
Other - Last Name:HAMLIN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-S, RD, CSSD, CSCS
Mailing Address - Street 1:1135 N MAY ST
Mailing Address - Street 2:
Mailing Address - City:SOUTHERN PINES
Mailing Address - State:NC
Mailing Address - Zip Code:28387-4207
Mailing Address - Country:US
Mailing Address - Phone:618-719-1992
Mailing Address - Fax:
Practice Address - Street 1:7473 NC 22 HWY STE C
Practice Address - Street 2:
Practice Address - City:WHISPERING PINES
Practice Address - State:NC
Practice Address - Zip Code:28327-8514
Practice Address - Country:US
Practice Address - Phone:910-215-5100
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-07-09
Last Update Date:2024-07-10
Deactivation Date:2020-10-08
Deactivation Code:
Reactivation Date:2020-10-14
Provider Licenses
StateLicense IDTaxonomies
NCL005380133V00000X
NC0010-11197363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No133V00000XDietary & Nutritional Service ProvidersDietitian, Registered