Provider Demographics
NPI:1215020961
Name:KADLEC-LOOBY, JENNIFER R (MD)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:R
Last Name:KADLEC-LOOBY
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4395 JOHNS CREEK PKWY STE 150
Mailing Address - Street 2:
Mailing Address - City:SUWANEE
Mailing Address - State:GA
Mailing Address - Zip Code:30024-6125
Mailing Address - Country:US
Mailing Address - Phone:770-814-1160
Mailing Address - Fax:
Practice Address - Street 1:4395 JOHNS CREEK PKWY STE 150
Practice Address - Street 2:
Practice Address - City:SUWANEE
Practice Address - State:GA
Practice Address - Zip Code:30024-6125
Practice Address - Country:US
Practice Address - Phone:770-814-1160
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-02
Last Update Date:2024-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA59254208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2192210Medicaid