Provider Demographics
NPI:1063448090
Name:HENSON, JENNIFER L (PA)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:L
Last Name:HENSON
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1571 HIGHWAY 21 S
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:GA
Mailing Address - Zip Code:31329-5214
Mailing Address - Country:US
Mailing Address - Phone:912-754-7500
Mailing Address - Fax:912-754-7505
Practice Address - Street 1:1571 HIGHWAY 21 S
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:GA
Practice Address - Zip Code:31329-3099
Practice Address - Country:US
Practice Address - Phone:912-754-7500
Practice Address - Fax:912-754-7505
Is Sole Proprietor?:No
Enumeration Date:2006-06-23
Last Update Date:2019-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA004058363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA1005914OtherAMERIGROUP
GA057423998BMedicaid
GA057423988AMedicaid
P29168Medicare UPIN
GA057423998BMedicaid
GA057423988AMedicaid
GA97WCDQKMedicare PIN