Provider Demographics
NPI:1720049208
Name:WAGNER-HITZEMAN, JENNIFER KRISTEN (MD)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:KRISTEN
Last Name:WAGNER-HITZEMAN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:JENNIFER
Other - Middle Name:KRISTEN
Other - Last Name:WAGNER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:3495 PIEDMONT RD NE
Mailing Address - Street 2:NINE PIEDMONT CENTER
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30305-1717
Mailing Address - Country:US
Mailing Address - Phone:404-504-5678
Mailing Address - Fax:
Practice Address - Street 1:750 TOWNPARK LN NW
Practice Address - Street 2:
Practice Address - City:KENNESAW
Practice Address - State:GA
Practice Address - Zip Code:30144-5579
Practice Address - Country:US
Practice Address - Phone:404-364-7285
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-04-01
Last Update Date:2022-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA053370208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA864857914AMedicaid