Provider Demographics
NPI:1104905710
Name:WOLFE, JENNIFER M (M-PA-C)
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:M
Last Name:WOLFE
Suffix:
Gender:F
Credentials:M-PA-C
Other - Prefix:
Other - First Name:JENNIFER
Other - Middle Name:M
Other - Last Name:SMITH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:16741 HIGHWAY 67 STE A
Mailing Address - Street 2:
Mailing Address - City:STATESBORO
Mailing Address - State:GA
Mailing Address - Zip Code:30458-2529
Mailing Address - Country:US
Mailing Address - Phone:912-871-7890
Mailing Address - Fax:912-871-7898
Practice Address - Street 1:16741 HIGHWAY 67 STE A
Practice Address - Street 2:
Practice Address - City:STATESBORO
Practice Address - State:GA
Practice Address - Zip Code:30458-2529
Practice Address - Country:US
Practice Address - Phone:912-871-7890
Practice Address - Fax:912-871-7898
Is Sole Proprietor?:No
Enumeration Date:2006-11-03
Last Update Date:2011-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA004532363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA379987348BMedicaid
GAQ53812Medicare UPIN
GA379987348BMedicaid