Healthcare Provider Details

I. General information

NPI: 1487083192
Provider Name (Legal Business Name): JENNIFER POTHOVEN DOUGHERTY NP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/03/2013
Last Update Date: 05/09/2022
Certification Date: 05/09/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2301 ERWIN ROAD CB #102346
DURHAM NC
27705
US

IV. Provider business mailing address

2301 ERWIN ROAD CB #102346
DURHAM NC
27705
US

V. Phone/Fax

Practice location:
  • Phone: 919-684-6335
  • Fax: 919-668-4859
Mailing address:
  • Phone: 919-684-6335
  • Fax: 919-668-4859

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163WP0200X
TaxonomyPediatric Registered Nurse
License NumberRN637152
License Number StatePA
# 2
Primary TaxonomyN
Taxonomy Code363LP0200X
TaxonomyPediatric Nurse Practitioner
License NumberSP013365
License Number StatePA
# 3
Primary TaxonomyY
Taxonomy Code363LP0200X
TaxonomyPediatric Nurse Practitioner
License Number5008859
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: