Healthcare Provider Details

I. General information

NPI: 1639728975
Provider Name (Legal Business Name): JESSICA GRIMES PATTON OD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: JESSICA DANIELLE GRIMES

II. Dates (important events)

Enumeration Date: 09/09/2019
Last Update Date: 07/21/2023
Certification Date: 07/21/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

868 YORK AVE SW
ATLANTA GA
30310-2750
US

IV. Provider business mailing address

868 YORK AVE SW
ATLANTA GA
30310-2750
US

V. Phone/Fax

Practice location:
  • Phone: 404-752-1400
  • Fax: 404-755-7400
Mailing address:
  • Phone: 404-752-1400
  • Fax: 404-755-7400

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number3191
License Number StateGA
# 2
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License NumberOPT003191
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: