Healthcare Provider Details

I. General information

NPI: 1306471685
Provider Name (Legal Business Name): TERRELL JENRETTE
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/07/2020
Last Update Date: 06/28/2023
Certification Date: 06/28/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1650 CHATTAHOOCHEE DR
ROCKMART GA
30153-2023
US

IV. Provider business mailing address

420 E 2ND AVE STE 103
ROME GA
30161-3210
US

V. Phone/Fax

Practice location:
  • Phone: 770-684-7846
  • Fax:
Mailing address:
  • Phone: 706-509-3000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number94161
License Number StateGA
# 2
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberUNKNOWN
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: