Provider Demographics
NPI:1306038591
Name:CARLQUIST, JENNIFER LEIGH (PAC)
Entity type:Individual
Prefix:MS
First Name:JENNIFER
Middle Name:LEIGH
Last Name:CARLQUIST
Suffix:
Gender:F
Credentials:PAC
Other - Prefix:MS
Other - First Name:JENNIFER
Other - Middle Name:LEIGH
Other - Last Name:CASE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:EMTP
Mailing Address - Street 1:1700 HOSPITAL SOUTH DR STE 409
Mailing Address - Street 2:
Mailing Address - City:AUSTELL
Mailing Address - State:GA
Mailing Address - Zip Code:30106-8159
Mailing Address - Country:US
Mailing Address - Phone:770-732-9100
Mailing Address - Fax:678-819-0359
Practice Address - Street 1:1700 HOSPITAL SOUTH DR STE 409
Practice Address - Street 2:
Practice Address - City:AUSTELL
Practice Address - State:GA
Practice Address - Zip Code:30106-8159
Practice Address - Country:US
Practice Address - Phone:770-732-9100
Practice Address - Fax:678-819-0359
Is Sole Proprietor?:No
Enumeration Date:2007-08-13
Last Update Date:2024-05-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA 19294363A00000X
GA12028363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA0PA192941Medicare PIN