Basic Information
| Provider Information | |||||||||
| NPI: | 1992109896 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | FOWLKES | ||||||||
| FirstName: | JENNIFER | ||||||||
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| Credential: | CRNP, FNP-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 33 MAGOTHY BEACH RD STE 102-103 | ||||||||
| Address2: | |||||||||
| City: | PASADENA | ||||||||
| State: | MD | ||||||||
| PostalCode: | 211224413 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4102557900 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 2140 KINGSLEY AVE STE 15 | ||||||||
| Address2: | |||||||||
| City: | ORANGE PARK | ||||||||
| State: | FL | ||||||||
| PostalCode: | 320735129 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9042130600 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/21/2014 | ||||||||
| LastUpdateDate: | 09/15/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 09/10/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 163W00000X | R177755 | MD | N | Nursing Service Providers | Registered Nurse | 363LF0000X | R177755 | MD | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
No ID Information.