Basic Information
| Provider Information | |||||||||
| NPI: | 1225622004 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MAI | ||||||||
| FirstName: | JENNIFER | ||||||||
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| Credential: | OD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1280 W PEACHTREE ST NW APT 1701 | ||||||||
| Address2: | |||||||||
| City: | ATLANTA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 303093434 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6173090387 | ||||||||
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| Practice Location | |||||||||
| Address1: | 105 PAVILION PKWY | ||||||||
| Address2: | |||||||||
| City: | FAYETTEVILLE | ||||||||
| State: | GA | ||||||||
| PostalCode: | 302144098 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7707161352 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 02/23/2021 | ||||||||
| LastUpdateDate: | 02/23/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 02/23/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 152W00000X | OPT003310 | GA | Y | Eye and Vision Services Providers | Optometrist |
No ID Information.