Provider Demographics
NPI:1750492716
Name:LEAGUE-SOBON, JENNIFER AMBER (MD)
Entity type:Individual
Prefix:DR
First Name:JENNIFER
Middle Name:AMBER
Last Name:LEAGUE-SOBON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 751803
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28275-1803
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:165 LOWES FOODS DR
Practice Address - Street 2:
Practice Address - City:LEWISVILLE
Practice Address - State:NC
Practice Address - Zip Code:27023-8258
Practice Address - Country:US
Practice Address - Phone:336-893-2270
Practice Address - Fax:336-893-2279
Is Sole Proprietor?:No
Enumeration Date:2006-08-31
Last Update Date:2023-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC9800947207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
98071OtherMEDCOST
0108388OtherUNITED HEALTHCARE
080161888OtherMEDICARE RAILROAD
126PAOtherBCBS
21272OtherCIGNA
7719318OtherAETNA
NC89126PAMedicaid
40709OtherPARTNERS
NC89126PAMedicaid
2276231Medicare PIN