Healthcare Provider Details

I. General information

NPI: 1376649871
Provider Name (Legal Business Name): JENNIFER N VERNON M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/15/2006
Last Update Date: 12/18/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1810 MULKEY RD SUITE 201
AUSTELL GA
30106-1151
US

IV. Provider business mailing address

1810 MULKEY RD SUITE 201
AUSTELL GA
30106-1151
US

V. Phone/Fax

Practice location:
  • Phone: 404-316-6269
  • Fax:
Mailing address:
  • Phone: 404-316-6269
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number18618
License Number StateMS
# 2
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number058830
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: