Provider Demographics
NPI:1255945184
Name:COLE, JENNIFER LYNNE (MED)
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:LYNNE
Last Name:COLE
Suffix:
Gender:F
Credentials:MED
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2450 HOPEHAVEN WAY
Mailing Address - Street 2:
Mailing Address - City:HOSCHTON
Mailing Address - State:GA
Mailing Address - Zip Code:30548-7404
Mailing Address - Country:US
Mailing Address - Phone:615-498-1823
Mailing Address - Fax:
Practice Address - Street 1:5555 GLENRIDGE CON SUITE 200
Practice Address - Street 2:
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30342
Practice Address - Country:US
Practice Address - Phone:470-361-2000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-09-08
Last Update Date:2020-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA18-74018106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician