Healthcare Provider Details

I. General information

NPI: 1336246289
Provider Name (Legal Business Name): FREDENA LUCAS JAGGERS CRNA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/20/2006
Last Update Date: 03/05/2024
Certification Date: 03/05/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2170 MIDLAND RD
SOUTHERN PINES NC
28387-2927
US

IV. Provider business mailing address

128 PEACHTREE LN STE B
ADVANCE NC
27006-6783
US

V. Phone/Fax

Practice location:
  • Phone: 910-295-1221
  • Fax:
Mailing address:
  • Phone: 336-624-1648
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number004545
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: