Healthcare Provider Details

I. General information

NPI: 1730058991
Provider Name (Legal Business Name): JACOB HENNEN
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/04/2025
Last Update Date: 07/02/2026
Certification Date: 07/02/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4700 NELSON BROGDON BLVD STE 240
BUFORD GA
30518-5401
US

IV. Provider business mailing address

4170 DAVIS RD
BUFORD GA
30518-4993
US

V. Phone/Fax

Practice location:
  • Phone: 770-271-3188
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License NumberPT018334
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: