Basic Information
| Provider Information | |||||||||
| NPI: | 1366109894 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BONEY | ||||||||
| FirstName: | JENNIFER | ||||||||
| MiddleName: | TILLMAN | ||||||||
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| Credential: | MSN, PMHNP-BC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2416 BEDGOOD DR SW | ||||||||
| Address2: | |||||||||
| City: | WILSON | ||||||||
| State: | NC | ||||||||
| PostalCode: | 278938515 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2522659200 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 208 MALLOY ST STE B | ||||||||
| Address2: | |||||||||
| City: | GOLDSBORO | ||||||||
| State: | NC | ||||||||
| PostalCode: | 275344478 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9845206080 | ||||||||
| FaxNumber: | 9845206081 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/18/2021 | ||||||||
| LastUpdateDate: | 06/30/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 06/30/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 163WP0808X | 171855 | NC | N | Nursing Service Providers | Registered Nurse | Psych/Mental Health | 363LP0808X | 5015694 | NC | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Psych/Mental Health |
No ID Information.