Provider Demographics
NPI:1710087101
Name:TANNER, JENNIFER HADDEN (PA-C)
Entity Type:Individual
Prefix:MRS
First Name:JENNIFER
Middle Name:HADDEN
Last Name:TANNER
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 1:1067 PEACHTREE ST
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30434-1558
Mailing Address - Country:US
Mailing Address - Phone:478-625-7000
Mailing Address - Fax:478-625-8907
Practice Address - Street 1:1067 PEACHTREE ST
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:GA
Practice Address - Zip Code:30434-1558
Practice Address - Country:US
Practice Address - Phone:478-625-7000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-09-25
Last Update Date:2018-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA004764363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA044692615AMedicaid
GA044692615AMedicaid