Provider Demographics
NPI:1780791657
Name:EVANGELISTA, JENNIFER ROBERTS (MD)
Entity type:Individual
Prefix:DR
First Name:JENNIFER
Middle Name:ROBERTS
Last Name:EVANGELISTA
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:JENNIFER
Other - Middle Name:ROBERTS
Other - Last Name:EVANGELIST
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:2416 CAPSTONE CT
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:GA
Mailing Address - Zip Code:31909-2795
Mailing Address - Country:US
Mailing Address - Phone:706-327-1281
Mailing Address - Fax:706-576-9714
Practice Address - Street 1:2416 CAPSTONE CT
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:GA
Practice Address - Zip Code:31909-2795
Practice Address - Country:US
Practice Address - Phone:706-327-1281
Practice Address - Fax:706-576-9714
Is Sole Proprietor?:No
Enumeration Date:2006-08-24
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA043037208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA043037OtherMEDICAL LICENSE
GABE5879195OtherDEA LICENSE
GA043037OtherMEDICAL LICENSE
GA00797123AMedicaid