=====================================================
General NPI Number Information
=====================================================
NPI Number | 1992059505
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JENNA NABORS MCDONALD CPNP
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/05/2012
-----------------------------------------------------
Last Update Date | 11/23/2012
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 9280 HIGHWAY 5 SUITE A
-----------------------------------------------------
City | DOUGLASVILLE
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30134-1501
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 770-942-5863
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 9280 HIGHWAY 5
-----------------------------------------------------
City | DOUGLASVILLE
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30134-1501
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 205-281-6655
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363LP0200X
-----------------------------------------------------
Taxonomy Name | Pediatric Nurse Practitioner
-----------------------------------------------------
License Number | RN226556
-----------------------------------------------------
License Number State | GA
-----------------------------------------------------