Healthcare Provider Details

I. General information

NPI: 1114705571
Provider Name (Legal Business Name): JENNIFER VILLEGAS PAC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/18/2023
Last Update Date: 04/13/2025
Certification Date: 04/13/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2200 MEDICAL CENTER BLVD STE 320
LAWRENCEVILLE GA
30046-7767
US

IV. Provider business mailing address

2200 MEDICAL CENTER BLVD STE 320
LAWRENCEVILLE GA
30046-7767
US

V. Phone/Fax

Practice location:
  • Phone: 470-325-1160
  • Fax: 678-701-9860
Mailing address:
  • Phone: 470-325-1160
  • Fax: 678-701-9860

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number13012
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: