Healthcare Provider Details

I. General information

NPI: 1427683424
Provider Name (Legal Business Name): JENISSA DAWN CORTES PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: JENISSA DAWN GORDON RD, PA-C

II. Dates (important events)

Enumeration Date: 03/10/2020
Last Update Date: 10/29/2024
Certification Date: 10/29/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1400 TULLIE RD NE
ATLANTA GA
30329-2309
US

IV. Provider business mailing address

5285 HOPGOOD RD
ACWORTH GA
30102-2427
US

V. Phone/Fax

Practice location:
  • Phone: 404-785-5247
  • Fax:
Mailing address:
  • Phone: 912-577-8510
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: