Healthcare Provider Details

I. General information

NPI: 1952307670
Provider Name (Legal Business Name): JENNIFER ROARK FNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/27/2005
Last Update Date: 10/07/2020
Certification Date: 10/07/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1856 THOMPSON BRIDGE RD STE 14
GAINESVILLE GA
30501-1620
US

IV. Provider business mailing address

PO BOX 742616
ATLANTA GA
30374-2616
US

V. Phone/Fax

Practice location:
  • Phone: 770-219-9460
  • Fax:
Mailing address:
  • Phone: 770-219-8420
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberRN097864
License Number StateGA
# 2
Primary TaxonomyN
Taxonomy Code363LP2300X
TaxonomyPrimary Care Nurse Practitioner
License NumberRN097864
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: