Provider Demographics
NPI:1689683179
Name:PARKS, JENNIFER CHRISTINE (MD)
Entity type:Individual
Prefix:DR
First Name:JENNIFER
Middle Name:CHRISTINE
Last Name:PARKS
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 751803
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28275-1803
Mailing Address - Country:US
Mailing Address - Phone:336-718-1000
Mailing Address - Fax:336-718-1050
Practice Address - Street 1:105 HANES SQUARE CIR
Practice Address - Street 2:
Practice Address - City:WINSTON SALEM
Practice Address - State:NC
Practice Address - Zip Code:27103-5514
Practice Address - Country:US
Practice Address - Phone:336-441-5569
Practice Address - Fax:336-771-1907
Is Sole Proprietor?:No
Enumeration Date:2006-08-05
Last Update Date:2021-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC2006-01163207P00000X, 207Q00000X
NC200601163207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC2057165AMedicaid
NC2057165AMedicaid
G94874Medicare UPIN