Provider Demographics
NPI:1629177324
Name:CHRISTIE, JENNETTA M (MD)
Entity Type:Individual
Prefix:
First Name:JENNETTA
Middle Name:M
Last Name:CHRISTIE
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 1:2317 BEMISS RD
Mailing Address - Street 2:
Mailing Address - City:VALDOSTA
Mailing Address - State:GA
Mailing Address - Zip Code:31602-1934
Mailing Address - Country:US
Mailing Address - Phone:229-244-7948
Mailing Address - Fax:
Practice Address - Street 1:2317 BEMISS RD
Practice Address - Street 2:
Practice Address - City:VALDOSTA
Practice Address - State:GA
Practice Address - Zip Code:31602-1934
Practice Address - Country:US
Practice Address - Phone:229-244-7948
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA030590207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
GAC36332Medicare UPIN