Provider Demographics
NPI:1184079196
Name:COBERNUS, JENNIFER B (DO)
Entity type:Individual
Prefix:DR
First Name:JENNIFER
Middle Name:B
Last Name:COBERNUS
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:JENNIFER
Other - Middle Name:L
Other - Last Name:BOSCH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 742616
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30374-2616
Mailing Address - Country:US
Mailing Address - Phone:770-219-8420
Mailing Address - Fax:
Practice Address - Street 1:852 DACULA RD
Practice Address - Street 2:
Practice Address - City:DACULA
Practice Address - State:GA
Practice Address - Zip Code:30019
Practice Address - Country:US
Practice Address - Phone:770-848-9360
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-04-27
Last Update Date:2021-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
GA82467207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program