Provider Demographics
NPI:1245369784
Name:DEFOREEST, JENNY R (CRNA)
Entity type:Individual
Prefix:
First Name:JENNY
Middle Name:R
Last Name:DEFOREEST
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1984 PEACHTREE RD NW
Mailing Address - Street 2:STE. 515
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30309-5219
Mailing Address - Country:US
Mailing Address - Phone:404-351-1754
Mailing Address - Fax:
Practice Address - Street 1:1640 AIRPORT RD NW
Practice Address - Street 2:STE. 110
Practice Address - City:KENNESAW
Practice Address - State:GA
Practice Address - Zip Code:30144-7038
Practice Address - Country:US
Practice Address - Phone:678-202-2074
Practice Address - Fax:678-290-0479
Is Sole Proprietor?:No
Enumeration Date:2007-03-02
Last Update Date:2021-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH020068367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA43ZLBJA77Medicare ID - Type Unspecified