Healthcare Provider Details

I. General information

NPI: 1992468474
Provider Name (Legal Business Name): JENNIFER SU MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/20/2021
Last Update Date: 07/10/2023
Certification Date: 07/10/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1447 HARPER ST
AUGUSTA GA
30912-1101
US

IV. Provider business mailing address

1004 CHAFEE AVE
AUGUSTA GA
30904-5810
US

V. Phone/Fax

Practice location:
  • Phone: 706-721-3291
  • Fax: 706-721-7960
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License Number13634
License Number StateGA
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: