Provider Demographics
NPI:1629572110
Name:ROSSIGNOL, JENNIFER UNDUTCH (FNP)
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:UNDUTCH
Last Name:ROSSIGNOL
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:JENNIFER
Other - Middle Name:NICOLE
Other - Last Name:UNDUTCH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:FNP
Mailing Address - Street 1:865 N HIGHLAND AVE NE
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30306-4565
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:865 N HIGHLAND AVE NE
Practice Address - Street 2:
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30306-4565
Practice Address - Country:US
Practice Address - Phone:404-733-6089
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-03-20
Last Update Date:2020-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZAP10887363LF0000X
CA95012490363LF0000X
GA218226363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZAP10887OtherSTATE LICENSE