Healthcare Provider Details

I. General information

NPI: 1417412792
Provider Name (Legal Business Name): JENNIFER THIESSEN FNP-C
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/31/2019
Last Update Date: 03/30/2023
Certification Date: 03/30/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6345 N CROATAN HWY
KITTY HAWK NC
27949-3887
US

IV. Provider business mailing address

6345 N CROATAN HWY STE 201
KITTY HAWK NC
27949-3887
US

V. Phone/Fax

Practice location:
  • Phone: 252-715-4466
  • Fax: 252-715-4468
Mailing address:
  • Phone: 252-715-4466
  • Fax: 252-715-4468

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207QA0401X
TaxonomyAddiction Medicine (Family Medicine) Physician
License Number5012458
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: