Basic Information
| Provider Information | |||||||||
| NPI: | 1083110597 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | JEN | ||||||||
| FirstName: | TIFFANY | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 746550 | ||||||||
| Address2: | |||||||||
| City: | ATLANTA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 303746550 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8882362263 | ||||||||
| FaxNumber: | 8443072857 | ||||||||
| Practice Location | |||||||||
| Address1: | 33 REBECCA DR | ||||||||
| Address2: | |||||||||
| City: | PALMYRA | ||||||||
| State: | VA | ||||||||
| PostalCode: | 229636242 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4346544680 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/03/2018 | ||||||||
| LastUpdateDate: | 07/05/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 07/05/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 238850 | NC | N | Allopathic & Osteopathic Physicians | Family Medicine | 207Q00000X | 8378851 | WI | N | Allopathic & Osteopathic Physicians | Family Medicine | 207Q00000X | 0101273658 | VA | Y | Allopathic & Osteopathic Physicians | Family Medicine |
No ID Information.