Healthcare Provider Details

I. General information

NPI: 1225031867
Provider Name (Legal Business Name): JENNIFER SANDERS PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/27/2005
Last Update Date: 11/23/2020
Certification Date: 11/23/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

101 HARTFORD RD W STE 1
FORT GAINES GA
39851-4331
US

IV. Provider business mailing address

250 MARTIN LUTHER KING JR BLVD
MACON GA
31201-3490
US

V. Phone/Fax

Practice location:
  • Phone: 229-210-2100
  • Fax: 478-301-5812
Mailing address:
  • Phone: 478-301-2362
  • Fax: 478-301-2272

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number003047
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: