Healthcare Provider Details

I. General information

NPI: 1699132787
Provider Name (Legal Business Name): JENNIE MATHEN NP-C
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/21/2016
Last Update Date: 12/12/2025
Certification Date: 12/12/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4120 FIVE FORKS TRICKUM RD SW STE 105
LILBURN GA
30047-8975
US

IV. Provider business mailing address

1897 INNSFAIL DR
SNELLVILLE GA
30078-2525
US

V. Phone/Fax

Practice location:
  • Phone: 404-778-0421
  • Fax:
Mailing address:
  • Phone: 678-458-3820
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberRN224236
License Number StateGA
# 2
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberRN224236
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: