Healthcare Provider Details

I. General information

NPI: 1841877917
Provider Name (Legal Business Name): JENNIFER BO LING YU-DATTA MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/25/2021
Last Update Date: 07/18/2025
Certification Date: 07/18/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

777 HEMLOCK ST # 165
MACON GA
31201-2102
US

IV. Provider business mailing address

777 HEMLOCK ST
MACON GA
31201-2102
US

V. Phone/Fax

Practice location:
  • Phone: 478-633-1000
  • Fax:
Mailing address:
  • Phone: 478-633-1000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number13431
License Number StateGA
# 3
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number99990
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: