Provider Demographics
NPI:1164772976
Name:LEIMBACH, JENNIFER L (PA)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:L
Last Name:LEIMBACH
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:JENNIFER
Other - Middle Name:L
Other - Last Name:SHIVELHOOD
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:590 LANIER AVE W
Mailing Address - Street 2:
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30214-1504
Mailing Address - Country:US
Mailing Address - Phone:678-688-9685
Mailing Address - Fax:770-626-3791
Practice Address - Street 1:131 FISCHER CROSSINGS DR
Practice Address - Street 2:
Practice Address - City:SHARPSBURG
Practice Address - State:GA
Practice Address - Zip Code:30277-3660
Practice Address - Country:US
Practice Address - Phone:678-590-5177
Practice Address - Fax:678-590-5404
Is Sole Proprietor?:No
Enumeration Date:2012-09-19
Last Update Date:2024-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
363A00000X
GA06610363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant