=====================================================
General NPI Number Information
=====================================================
NPI Number | 1457571432
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JENNIFER CAROL PICKENS MD
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/01/2007
-----------------------------------------------------
Last Update Date | 09/01/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 412 S JONES ST
-----------------------------------------------------
City | PEMBROKE
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 28372-7261
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 910-521-4462
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 1847
-----------------------------------------------------
City | LAURINBURG
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 28353-1847
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207Q00000X
-----------------------------------------------------
Taxonomy Name | Family Medicine Physician
-----------------------------------------------------
License Number | 39947
-----------------------------------------------------
License Number State | SC
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 207Q00000X
-----------------------------------------------------
Taxonomy Name | Family Medicine Physician
-----------------------------------------------------
License Number | 2005-01862
-----------------------------------------------------
License Number State | NC
-----------------------------------------------------