Provider Demographics
NPI:1770512675
Name:AQUA, JENNIFER BETH (MD)
Entity Type:Individual
Prefix:DR
First Name:JENNIFER
Middle Name:BETH
Last Name:AQUA
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:960 JOHNSON FERRY RD NE
Mailing Address - Street 2:STE 400
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30342-4771
Mailing Address - Country:US
Mailing Address - Phone:404-257-0170
Mailing Address - Fax:404-851-9894
Practice Address - Street 1:960 JOHNSON FERRY RD NE
Practice Address - Street 2:STE 400
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30342-4771
Practice Address - Country:US
Practice Address - Phone:404-257-0170
Practice Address - Fax:404-851-9894
Is Sole Proprietor?:No
Enumeration Date:2006-07-02
Last Update Date:2011-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA044882207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA013526OtherBLUE CROSS BLUE SHIELD
GA160052432OtherRAILROAD MEDICARE
GA0701009OtherUNITED HEALTHCARE
GA00804273UMedicaid
GA2624404OtherAETNA/USHC
GA5857673OtherAETNA/USHC
GA000804273VMedicaid
GA00804273RMedicaid
GA000804273WMedicaid
GA16BDTVBMedicare ID - Type Unspecified
GA00804273UMedicaid