Provider Demographics
NPI:1821133737
Name:FORTNER, JENNIFER FLAMM (MD)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:FLAMM
Last Name:FORTNER
Suffix:
Gender:F
Credentials:MD
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Mailing Address - Street 1:3435 BULLOCH LAKE RD
Mailing Address - Street 2:
Mailing Address - City:LOGANVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30052-8648
Mailing Address - Country:US
Mailing Address - Phone:404-791-5840
Mailing Address - Fax:404-385-5111
Practice Address - Street 1:740 FERST DR NW
Practice Address - Street 2:
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30332-0470
Practice Address - Country:US
Practice Address - Phone:404-385-4380
Practice Address - Fax:404-385-5111
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-20
Last Update Date:2007-07-08
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
GA0547182084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
GAH27854Medicare UPIN