Healthcare Provider Details

I. General information

NPI: 1942028121
Provider Name (Legal Business Name): JORDAN JENNA PAYNE RN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/27/2024
Last Update Date: 09/27/2024
Certification Date: 09/27/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1520 CLIFTON RD NE
ATLANTA GA
30322-4201
US

IV. Provider business mailing address

2850 SEAGRAVE WAY
MARIETTA GA
30066-3688
US

V. Phone/Fax

Practice location:
  • Phone: 404-727-7980
  • Fax:
Mailing address:
  • Phone: 470-233-2375
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License NumberRN332275
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: