Provider Demographics
NPI:1891369120
Name:BERTRAM, JENNIFER MICHELLE
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:MICHELLE
Last Name:BERTRAM
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 1:771 ROUNDTREE DR SW STE A
Mailing Address - Street 2:
Mailing Address - City:DAWSON
Mailing Address - State:GA
Mailing Address - Zip Code:39842-1683
Mailing Address - Country:US
Mailing Address - Phone:229-270-1905
Mailing Address - Fax:229-270-1915
Practice Address - Street 1:771 ROUNDTREE DR SW STE A
Practice Address - Street 2:
Practice Address - City:DAWSON
Practice Address - State:GA
Practice Address - Zip Code:39842-1683
Practice Address - Country:US
Practice Address - Phone:229-270-1905
Practice Address - Fax:229-270-1915
Is Sole Proprietor?:No
Enumeration Date:2021-05-20
Last Update Date:2023-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN269136363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily