Healthcare Provider Details

I. General information

NPI: 1750352423
Provider Name (Legal Business Name): JENNIFER MCDONALD WILLARD M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/30/2006
Last Update Date: 10/31/2024
Certification Date: 10/31/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1030 SIENA DRIVE
RALEIGH NC
27587-2781
US

IV. Provider business mailing address

PO BOX 602195
CHARLOTTE NC
28260-2195
US

V. Phone/Fax

Practice location:
  • Phone: 919-235-6511
  • Fax: 919-341-3578
Mailing address:
  • Phone: 919-350-0351
  • Fax: 919-350-7687

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2080A0000X
TaxonomyPediatric Adolescent Medicine Physician
License Number9701657
License Number StateNC
# 2
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number9701657
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: