Healthcare Provider Details

I. General information

NPI: 1871593582
Provider Name (Legal Business Name): JENNIFER M SANDERSON DO
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/22/2005
Last Update Date: 06/22/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1805 VERNON RD STE C
LAGRANGE GA
30240-4041
US

IV. Provider business mailing address

1805 VERNON RD STE C
LAGRANGE GA
30240-4041
US

V. Phone/Fax

Practice location:
  • Phone: 706-812-9902
  • Fax: 706-812-0802
Mailing address:
  • Phone: 706-812-9902
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License Number053028
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: