Healthcare Provider Details

I. General information

NPI: 1184240426
Provider Name (Legal Business Name): JENNA WALTON FNP-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/23/2020
Last Update Date: 08/07/2026
Certification Date: 08/07/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

127 OLD HIGHWAY 96 STE B
BONAIRE GA
31005-3461
US

IV. Provider business mailing address

PO BOX 117598
ATLANTA GA
30368-7598
US

V. Phone/Fax

Practice location:
  • Phone: 478-352-7143
  • Fax: 478-352-7144
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License NumberRN275278
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: