Provider Demographics
NPI:1952367138
Name:MABLEY, JILL ANN (MD)
Entity type:Individual
Prefix:
First Name:JILL
Middle Name:ANN
Last Name:MABLEY
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 708
Mailing Address - Street 2:
Mailing Address - City:LEBANON
Mailing Address - State:GA
Mailing Address - Zip Code:30146-0708
Mailing Address - Country:US
Mailing Address - Phone:678-493-4000
Mailing Address - Fax:
Practice Address - Street 1:660 W CROSSVILLE RD
Practice Address - Street 2:SUITE 110
Practice Address - City:ROSWELL
Practice Address - State:GA
Practice Address - Zip Code:30075-7525
Practice Address - Country:US
Practice Address - Phone:678-555-5555
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-04-25
Last Update Date:2008-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA021581207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000788114DMedicaid
GA000788114DMedicaid