Healthcare Provider Details

I. General information

NPI: 1841660768
Provider Name (Legal Business Name): JENNIFER SISCO
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/05/2015
Last Update Date: 08/11/2022
Certification Date: 08/11/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

55 CARLTON ST
ATHENS GA
30602-1407
US

IV. Provider business mailing address

55 CARTON ST
ATHENS GA
30602-0001
US

V. Phone/Fax

Practice location:
  • Phone: 706-542-2273
  • Fax: 706-542-8661
Mailing address:
  • Phone: 706-542-2273
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License NumberA004547
License Number StateAR
# 2
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License NumberRN274159
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: