Healthcare Provider Details

I. General information

NPI: 1366533143
Provider Name (Legal Business Name): JENNIFER RICHARDSON ECSE
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/27/2006
Last Update Date: 07/09/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7950 MARTIN LOOP
FORT BENNING GA
31905-5647
US

IV. Provider business mailing address

7950 MARTIN LOOP
FORT BENNING GA
31905-5647
US

V. Phone/Fax

Practice location:
  • Phone: 706-545-9116
  • Fax: 706-545-5572
Mailing address:
  • Phone: 706-545-9116
  • Fax: 706-545-5572

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171W00000X
TaxonomyContractor
License Number655026
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: