Healthcare Provider Details

I. General information

NPI: 1679431761
Provider Name (Legal Business Name): JESSICA KC PMHNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/15/2026
Last Update Date: 08/11/2026
Certification Date: 08/11/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11539 PARK WOODS CIR STE 603
ALPHARETTA GA
30005-2413
US

IV. Provider business mailing address

11539 PARK WOODS CIR STE 603
ALPHARETTA GA
30005-2413
US

V. Phone/Fax

Practice location:
  • Phone: 678-615-7032
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License NumberAPRN-NP319377
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: