Provider Demographics
NPI:1205085198
Name:CHILDRESS, JENNIFER GREENE (RN)
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:GREENE
Last Name:CHILDRESS
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1966 MORGANTON BLVD SW STE B
Mailing Address - Street 2:
Mailing Address - City:LENOIR
Mailing Address - State:NC
Mailing Address - Zip Code:28645-5311
Mailing Address - Country:US
Mailing Address - Phone:828-426-8448
Mailing Address - Fax:828-426-8527
Practice Address - Street 1:1966 MORGANTON BLVD SW STE B
Practice Address - Street 2:
Practice Address - City:LENOIR
Practice Address - State:NC
Practice Address - Zip Code:28645-5311
Practice Address - Country:US
Practice Address - Phone:828-426-8448
Practice Address - Fax:828-426-8527
Is Sole Proprietor?:No
Enumeration Date:2008-09-16
Last Update Date:2008-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC136175163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC136175OtherRN
NC8300175KMedicaid