Healthcare Provider Details

I. General information

NPI: 1518588326
Provider Name (Legal Business Name): JESSICA CISNEROS RT (R)
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: JESSICA CISNEROS RT (R)

II. Dates (important events)

Enumeration Date: 05/03/2020
Last Update Date: 05/03/2020
Certification Date: 05/03/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1000 JOHNSON FERRY RD
ATLANTA GA
30342-1611
US

IV. Provider business mailing address

70 PERIMETER CTR E APT 1438
ATLANTA GA
30346-1828
US

V. Phone/Fax

Practice location:
  • Phone: 404-851-8000
  • Fax:
Mailing address:
  • Phone: 706-618-0106
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number576116
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: