Provider Demographics
NPI:1689080996
Name:BADARACCO, JENNIFER SONG (OD)
Entity Type:Individual
Prefix:DR
First Name:JENNIFER
Middle Name:SONG
Last Name:BADARACCO
Suffix:
Gender:F
Credentials:OD
Other - Prefix:DR
Other - First Name:JENNIFER
Other - Middle Name:
Other - Last Name:SONG
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:OD
Mailing Address - Street 1:5777 OLD WINDER HWY
Mailing Address - Street 2:
Mailing Address - City:BRASELTON
Mailing Address - State:GA
Mailing Address - Zip Code:30517-1603
Mailing Address - Country:US
Mailing Address - Phone:770-965-5101
Mailing Address - Fax:
Practice Address - Street 1:5777 OLD WINDER HWY
Practice Address - Street 2:
Practice Address - City:BRASELTON
Practice Address - State:GA
Practice Address - Zip Code:30517-1603
Practice Address - Country:US
Practice Address - Phone:770-965-5101
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-07-08
Last Update Date:2018-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAOPT002861152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist