Provider Demographics
NPI:1053537035
Name:JERNIGAN, AUDREY LEE (LMT)
Entity type:Individual
Prefix:MISS
First Name:AUDREY
Middle Name:LEE
Last Name:JERNIGAN
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:54 MACARIS ST
Mailing Address - Street 2:
Mailing Address - City:ST AUGUSTINE
Mailing Address - State:FL
Mailing Address - Zip Code:32084-2164
Mailing Address - Country:US
Mailing Address - Phone:904-392-5399
Mailing Address - Fax:904-819-5851
Practice Address - Street 1:212 SAN MARCO AVE
Practice Address - Street 2:
Practice Address - City:ST AUGUSTINE
Practice Address - State:FL
Practice Address - Zip Code:32084-2773
Practice Address - Country:US
Practice Address - Phone:904-392-5399
Practice Address - Fax:904-819-5851
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-18
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL35509174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist