Provider Demographics
NPI:1144497736
Name:MULLIS GRANT, JENNIFER MARIE (PA)
Entity type:Individual
Prefix:MRS
First Name:JENNIFER
Middle Name:MARIE
Last Name:MULLIS GRANT
Suffix:
Gender:F
Credentials:PA
Other - Prefix:MRS
Other - First Name:JENNIFER
Other - Middle Name:MARIE
Other - Last Name:GRANT
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:PA
Mailing Address - Street 1:1032 WARWICK DR
Mailing Address - Street 2:
Mailing Address - City:MACON
Mailing Address - State:GA
Mailing Address - Zip Code:31210-1540
Mailing Address - Country:US
Mailing Address - Phone:478-731-6297
Mailing Address - Fax:
Practice Address - Street 1:140 N CREST BLVD
Practice Address - Street 2:
Practice Address - City:MACON
Practice Address - State:GA
Practice Address - Zip Code:31210-1845
Practice Address - Country:US
Practice Address - Phone:478-757-8335
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-05-13
Last Update Date:2013-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA005270363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant