Provider Demographics
NPI:1235302753
Name:WOOD, JENNIFER GWEN (PA-C)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:GWEN
Last Name:WOOD
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:240 SHERATON BLVD
Mailing Address - Street 2:
Mailing Address - City:MACON
Mailing Address - State:GA
Mailing Address - Zip Code:31210-1358
Mailing Address - Country:US
Mailing Address - Phone:478-471-1943
Mailing Address - Fax:478-475-9780
Practice Address - Street 1:240 SHERATON BLVD
Practice Address - Street 2:
Practice Address - City:MACON
Practice Address - State:GA
Practice Address - Zip Code:31210-1358
Practice Address - Country:US
Practice Address - Phone:478-471-1943
Practice Address - Fax:478-475-9780
Is Sole Proprietor?:No
Enumeration Date:2008-04-04
Last Update Date:2011-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA005329363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA322789982BMedicaid
GA322789982BMedicaid