Provider Demographics
NPI:1639809254
Name:LANDRY, JENNIFER
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:
Last Name:LANDRY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:777 HEMLOCK ST
Mailing Address - Street 2:
Mailing Address - City:MACON
Mailing Address - State:GA
Mailing Address - Zip Code:31201-2102
Mailing Address - Country:US
Mailing Address - Phone:478-633-7140
Mailing Address - Fax:478-633-5142
Practice Address - Street 1:1600 UNION MEETING RD APT 324
Practice Address - Street 2:
Practice Address - City:BLUE BELL
Practice Address - State:PA
Practice Address - Zip Code:19422-2096
Practice Address - Country:US
Practice Address - Phone:706-718-7073
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-06-15
Last Update Date:2025-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA105512208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics