Basic Information
| Provider Information | |||||||||
| NPI: | 1164720090 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | DAWE | ||||||||
| FirstName: | JENNIFER | ||||||||
| MiddleName: | JORDAN | ||||||||
| NamePrefix: | MRS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | NP-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1835 SAVOY DR | ||||||||
| Address2: | SUITE 300 | ||||||||
| City: | ATLANTA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 303411072 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7709420457 | ||||||||
| FaxNumber: | 7709427699 | ||||||||
| Practice Location | |||||||||
| Address1: | 4586 TIMBER RIDGE DR | ||||||||
| Address2: | SUITE 200 | ||||||||
| City: | DOUGLASVILLE | ||||||||
| State: | GA | ||||||||
| PostalCode: | 301357517 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7709420457 | ||||||||
| FaxNumber: | 7709427699 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/01/2011 | ||||||||
| LastUpdateDate: | 08/19/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 08/19/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LA2200X | RN171108 | GA | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Adult Health | 363L00000X | RN171108 | GA | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |
ID Information
| ID | Type | State | Issuer | Description | 003108710D | 05 | GA | MEDICAID | 003108710E | 05 | GA | MEDICAID |