Healthcare Provider Details

I. General information

NPI: 1700449915
Provider Name (Legal Business Name): JESSICA DAVIS DO
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/15/2019
Last Update Date: 07/17/2022
Certification Date: 07/17/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1459 LANEY WALKER BLVD AE 3042
AUGUSTA GA
30912
US

IV. Provider business mailing address

1083 COLUMN WAY APT 205
FOREST VA
24551-1888
US

V. Phone/Fax

Practice location:
  • Phone: 706-721-3466
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number10826
License Number StateGA
# 2
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number82287
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: