Healthcare Provider Details

I. General information

NPI: 1578483202
Provider Name (Legal Business Name): JENNIFER LUKE FNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/21/2026
Last Update Date: 07/21/2026
Certification Date: 07/21/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1623 MADISON AVE
TIFTON GA
31794-3757
US

IV. Provider business mailing address

22 WATERS EDGE WAY
TIFTON GA
31793-1135
US

V. Phone/Fax

Practice location:
  • Phone: 229-353-7720
  • Fax:
Mailing address:
  • Phone: 229-343-6069
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberAPRN-NP215960
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: