MEDICARE: JENNIE MATHEN NP-C

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207R00000X	Internal Medicine Physician	RN224236	GA
2	363LF0000X	Family Nurse Practitioner	RN224236	GA

General Provider Information

NPI Number	:	1699132787
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JENNIE MATHEN NP-C

Provider Business Mailing Address
First Line	:	1897 INNSFAIL DR
Second Line	:
City	:	SNELLVILLE
State	:	GA
Zip	:	30078-2525
Country	:	US
Telephone Number	:	678-458-3820
Fax Number	:

Provider Business Practice Location Address
First Line	:	4120 FIVE FORKS TRICKUM RD SW STE 105
Second Line	:
City	:	LILBURN
State	:	GA
Zip	:	30047-8975
Country	:	US
Telephone Number	:	404-778-0421
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	01/21/2016
Last Update Date	:	12/12/2025

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