Healthcare Provider Details

I. General information

NPI: 1558143032
Provider Name (Legal Business Name): JENNIFER GAMBLE PA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/18/2023
Last Update Date: 12/28/2023
Certification Date: 12/28/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

95 COLLIER RD NW STE 2065
ATLANTA GA
30309-1705
US

IV. Provider business mailing address

4381 LAKE IDYLWILDE DR
EVANS GA
30809-3047
US

V. Phone/Fax

Practice location:
  • Phone: 404-605-2800
  • Fax:
Mailing address:
  • Phone: 706-829-3211
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number11977
License Number StateGA
# 2
Primary TaxonomyN
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License Number11977
License Number StateGA
# 3
Primary TaxonomyN
Taxonomy Code207RA0001X
TaxonomyAdvanced Heart Failure and Transplant Cardiology Physician
License Number11977
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: