Provider Demographics
NPI:1750670634
Name:JEAN, JENNEFER LOURDES
Entity Type:Individual
Prefix:
First Name:JENNEFER
Middle Name:LOURDES
Last Name:JEAN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2124 GRANT AVE
Mailing Address - Street 2:
Mailing Address - City:MCDONOUGH
Mailing Address - State:GA
Mailing Address - Zip Code:30252-7696
Mailing Address - Country:US
Mailing Address - Phone:954-274-4682
Mailing Address - Fax:770-914-8958
Practice Address - Street 1:2124 GRANT AVE
Practice Address - Street 2:
Practice Address - City:MCDONOUGH
Practice Address - State:GA
Practice Address - Zip Code:30252-7696
Practice Address - Country:US
Practice Address - Phone:954-274-4682
Practice Address - Fax:770-914-8958
Is Sole Proprietor?:Yes
Enumeration Date:2011-03-31
Last Update Date:2011-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374U00000XNursing Service Related ProvidersHome Health Aide
No3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant