Provider Demographics
NPI:1750096103
Name:LE, JENNIFER NGUYEN (PA-C)
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:NGUYEN
Last Name:LE
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1204 NOBLE VINES DR APT 1204
Mailing Address - Street 2:
Mailing Address - City:BUFORD
Mailing Address - State:GA
Mailing Address - Zip Code:30519-6112
Mailing Address - Country:US
Mailing Address - Phone:404-518-5064
Mailing Address - Fax:
Practice Address - Street 1:2690 HAMILTON MILL RD STE 100
Practice Address - Street 2:
Practice Address - City:BUFORD
Practice Address - State:GA
Practice Address - Zip Code:30519-4193
Practice Address - Country:US
Practice Address - Phone:470-326-7300
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-01-19
Last Update Date:2023-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
363A00000X
GA11342363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant