Healthcare Provider Details

I. General information

NPI: 1477604098
Provider Name (Legal Business Name): JENNIFER CROSS DAVIS RN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: JENNIFER LEIGH CROSS RN

II. Dates (important events)

Enumeration Date: 01/12/2007
Last Update Date: 09/27/2022
Certification Date: 09/27/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

13570 N MAIN ST
TRENTON GA
30752-2012
US

IV. Provider business mailing address

13570 N MAIN ST
TRENTON GA
30752-2012
US

V. Phone/Fax

Practice location:
  • Phone: 706-956-2665
  • Fax:
Mailing address:
  • Phone: 706-956-2665
  • Fax: 706-657-2958

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0200X
TaxonomyPediatric Nurse Practitioner
License NumberRN148442
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: