Provider Demographics
NPI:1699132787
Name:MATHEN, JENNIE (NP-C)
Entity type:Individual
Prefix:
First Name:JENNIE
Middle Name:
Last Name:MATHEN
Suffix:
Gender:F
Credentials:NP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2800 TUSCANY PARK DR
Mailing Address - Street 2:
Mailing Address - City:LAWRENCEVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30043-1345
Mailing Address - Country:US
Mailing Address - Phone:678-458-3820
Mailing Address - Fax:
Practice Address - Street 1:2800 TUSCANY PARK DR
Practice Address - Street 2:
Practice Address - City:LAWRENCEVILLE
Practice Address - State:GA
Practice Address - Zip Code:30043-1345
Practice Address - Country:US
Practice Address - Phone:678-458-3820
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-01-21
Last Update Date:2016-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN224236363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily