Healthcare Provider Details

I. General information

NPI: 1174327357
Provider Name (Legal Business Name): JENNIFER YVONNE FORD NP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: JENNIFER YVONNE FORD NP

II. Dates (important events)

Enumeration Date: 04/04/2025
Last Update Date: 10/10/2025
Certification Date: 10/10/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

101 QUARTZ DR STE 101
VILLA RICA GA
30180-3256
US

IV. Provider business mailing address

101 QUARTZ DR STE 101
VILLA RICA GA
30180-3256
US

V. Phone/Fax

Practice location:
  • Phone: 770-812-0445
  • Fax: 770-942-8800
Mailing address:
  • Phone: 770-836-9445
  • Fax: 770-836-8808

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License NumberAPRN-NP137808
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: