Healthcare Provider Details

I. General information

NPI: 1558196857
Provider Name (Legal Business Name): JENNIFER FRUTOS PMHNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/05/2024
Last Update Date: 11/13/2024
Certification Date: 11/13/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4102 BEN FRANKLIN BLVD
DURHAM NC
27704-2140
US

IV. Provider business mailing address

350 HIDDEN LAKE DR
YOUNGSVILLE NC
27596-7470
US

V. Phone/Fax

Practice location:
  • Phone: 919-972-7700
  • Fax:
Mailing address:
  • Phone: 305-733-9095
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number5020825
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: