Healthcare Provider Details

I. General information

NPI: 1053397919
Provider Name (Legal Business Name): JENNIFER MARION MCCREARY FNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/21/2005
Last Update Date: 07/09/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

800 W WILLIAMS ST
APEX NC
27502-5203
US

IV. Provider business mailing address

1600 PERIMETER PARK DR SUITE 225
MORRISVILLE NC
27560-8421
US

V. Phone/Fax

Practice location:
  • Phone: 919-363-9363
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number2000801
License Number StateNC

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier7005242
Identifier TypeMEDICAID
Identifier StateNC
Identifier Issuer
# 2
Identifier200801
Identifier TypeOTHER
Identifier StateNY
Identifier IssuerMEDICAL LICENSE NUMBER

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: