Provider Demographics
NPI:1841580180
Name:GEORGIA, JENNIFER ANN (PA)
Entity Type:Individual
Prefix:MRS
First Name:JENNIFER
Middle Name:ANN
Last Name:GEORGIA
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:JENNIFER
Other - Middle Name:ANN
Other - Last Name:GILBERT (MAIDENT)
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA
Mailing Address - Street 1:2300 HAGGERTY RD
Mailing Address - Street 2:STE 1110
Mailing Address - City:WEST BLOOMFIELD
Mailing Address - State:MI
Mailing Address - Zip Code:48323
Mailing Address - Country:US
Mailing Address - Phone:248-669-2000
Mailing Address - Fax:248-669-2110
Practice Address - Street 1:2300 HAGGERTY RD
Practice Address - Street 2:STE 1110
Practice Address - City:WEST BLOOMFIELD
Practice Address - State:MI
Practice Address - Zip Code:48323
Practice Address - Country:US
Practice Address - Phone:248-669-2000
Practice Address - Fax:248-669-2110
Is Sole Proprietor?:No
Enumeration Date:2011-04-07
Last Update Date:2014-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5601007054363AM0700X, 363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical