Provider Demographics
NPI:1992109896
Name:FOWLKES, JENNIFER (CRNP, FNP-C)
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:
Last Name:FOWLKES
Suffix:
Gender:F
Credentials:CRNP, FNP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:33 MAGOTHY BEACH RD STE 102-103
Mailing Address - Street 2:
Mailing Address - City:PASADENA
Mailing Address - State:MD
Mailing Address - Zip Code:21122-4413
Mailing Address - Country:US
Mailing Address - Phone:410-255-7900
Mailing Address - Fax:
Practice Address - Street 1:2140 KINGSLEY AVE STE 15
Practice Address - Street 2:
Practice Address - City:ORANGE PARK
Practice Address - State:FL
Practice Address - Zip Code:32073-5129
Practice Address - Country:US
Practice Address - Phone:904-213-0600
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-10-21
Last Update Date:2021-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDR177755163W00000X, 363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163W00000XNursing Service ProvidersRegistered Nurse