Basic Information
| Provider Information | |||||||||
| NPI: | 1902491954 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | JERNIGAN | ||||||||
| FirstName: | ASHLEY | ||||||||
| MiddleName: | KRISTEN | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1810 HAY RD | ||||||||
| Address2: | |||||||||
| City: | BEAVERTON | ||||||||
| State: | MI | ||||||||
| PostalCode: | 486129489 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9893241154 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1234 W CEDAR AVE | ||||||||
| Address2: | |||||||||
| City: | GLADWIN | ||||||||
| State: | MI | ||||||||
| PostalCode: | 486241818 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9897095413 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 03/02/2021 | ||||||||
| LastUpdateDate: | 03/02/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 01/29/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 106S00000X | J652072478599 | MI | Y |
No ID Information.