Healthcare Provider Details

I. General information

NPI: 1740741628
Provider Name (Legal Business Name): JENNA GORBATKIN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/25/2019
Last Update Date: 04/13/2022
Certification Date: 04/13/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

49 JESSE HILL JR DR SE
ATLANTA GA
30303-3049
US

IV. Provider business mailing address

49 JESSE HILL JR DR SE
ATLANTA GA
30303-3049
US

V. Phone/Fax

Practice location:
  • Phone: 404-778-1440
  • Fax: 404-778-1401
Mailing address:
  • Phone: 404-778-1440
  • Fax: 404-778-1401

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number91625
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: