Provider Demographics
NPI:1063512523
Name:HODGES, JENNIE L (PA)
Entity type:Individual
Prefix:
First Name:JENNIE
Middle Name:L
Last Name:HODGES
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:JENNIE
Other - Middle Name:L
Other - Last Name:PILL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1499 WALTON WAY
Mailing Address - Street 2:STE 1400
Mailing Address - City:AUGUSTA
Mailing Address - State:GA
Mailing Address - Zip Code:30901-2650
Mailing Address - Country:US
Mailing Address - Phone:706-724-6100
Mailing Address - Fax:
Practice Address - Street 1:1120 15TH ST
Practice Address - Street 2:
Practice Address - City:AUGUSTA
Practice Address - State:GA
Practice Address - Zip Code:30912-0004
Practice Address - Country:US
Practice Address - Phone:706-721-2542
Practice Address - Fax:706-721-6676
Is Sole Proprietor?:No
Enumeration Date:2006-09-25
Last Update Date:2011-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA001865363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC0148PAMedicaid
GA100002064AMedicaid
GA97BBDPTMedicare ID - Type UnspecifiedGA MEDICARE
S72394Medicare UPIN