Provider Demographics
NPI:1245363688
Name:JERNIGAN, AUDREY D
Entity type:Individual
Prefix:MRS
First Name:AUDREY
Middle Name:D
Last Name:JERNIGAN
Suffix:
Gender:F
Credentials:
Other - Prefix:MRS
Other - First Name:AUDREY
Other - Middle Name:D
Other - Last Name:JERNIGAN
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:PT
Mailing Address - Street 1:301 PINEVIEW DR
Mailing Address - Street 2:
Mailing Address - City:WAYCROSS
Mailing Address - State:GA
Mailing Address - Zip Code:31501-5229
Mailing Address - Country:US
Mailing Address - Phone:912-285-2361
Mailing Address - Fax:912-285-0571
Practice Address - Street 1:301 PINEVIEW DR.
Practice Address - Street 2:
Practice Address - City:WAYCROSS
Practice Address - State:GA
Practice Address - Zip Code:31501
Practice Address - Country:US
Practice Address - Phone:912-285-2361
Practice Address - Fax:912-285-0571
Is Sole Proprietor?:No
Enumeration Date:2007-03-14
Last Update Date:2013-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPT001243225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA659CBGPMedicare ID - Type UnspecifiedGEORGIA
GA650002986Medicare ID - Type UnspecifiedRAILROAD