Basic Information
| Provider Information | |||||||||
| NPI: | 1457571432 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | PICKENS | ||||||||
| FirstName: | JENNIFER | ||||||||
| MiddleName: | CAROL | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 1847 | ||||||||
| Address2: | |||||||||
| City: | LAURINBURG | ||||||||
| State: | NC | ||||||||
| PostalCode: | 283531847 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 412 S JONES ST | ||||||||
| Address2: | |||||||||
| City: | PEMBROKE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 283727261 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9105214462 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/01/2007 | ||||||||
| LastUpdateDate: | 09/01/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 08/31/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 39947 | SC | N | Allopathic & Osteopathic Physicians | Family Medicine | 207Q00000X | 2005-01862 | NC | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 1457571432 | 05 | NC | MEDICAID | NC1220 | 05 | SC | MEDICAID |