Healthcare Provider Details

I. General information

NPI: 1568793560
Provider Name (Legal Business Name): JILL CZEBATOL HENDRIX PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/15/2010
Last Update Date: 11/06/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

55 WHITCHER ST NE SUITE 420
MARIETTA GA
30060-1155
US

IV. Provider business mailing address

55 WHITCHER ST NE SUITE 420
MARIETTA GA
30060-1155
US

V. Phone/Fax

Practice location:
  • Phone: 770-422-1372
  • Fax: 770-423-9651
Mailing address:
  • Phone: 770-422-1372
  • Fax: 770-423-9651

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number004118
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: