Healthcare Provider Details

I. General information

NPI: 1689356388
Provider Name (Legal Business Name): JESSE ELI MACDONALD FNP-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/02/2023
Last Update Date: 12/06/2024
Certification Date: 12/06/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1365 CLIFTON RD NE FL 1
ATLANTA GA
30322-1013
US

IV. Provider business mailing address

1365 CLIFTON RD NE FL 1
ATLANTA GA
30322-1013
US

V. Phone/Fax

Practice location:
  • Phone: 404-778-3184
  • Fax:
Mailing address:
  • Phone: 404-778-3184
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberAP61473760
License Number StateWA
# 2
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberRN330008
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: