Provider Demographics
NPI:1487997664
Name:GUSTAFSON, JENNIFER K (MD)
Entity type:Individual
Prefix:DR
First Name:JENNIFER
Middle Name:K
Last Name:GUSTAFSON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2700 MOUNT OLIVE DR
Mailing Address - Street 2:
Mailing Address - City:DECATUR
Mailing Address - State:GA
Mailing Address - Zip Code:30033-2930
Mailing Address - Country:US
Mailing Address - Phone:941-315-3604
Mailing Address - Fax:
Practice Address - Street 1:5673 PEACHTREE DUNWOODY RD STE 700
Practice Address - Street 2:
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30342-1752
Practice Address - Country:US
Practice Address - Phone:404-778-3401
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-04-05
Last Update Date:2017-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA78311207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology