Healthcare Provider Details

I. General information

NPI: 1508859992
Provider Name (Legal Business Name): JESSICA GREER ZOMBEK RD, LD
Entity Type: Individual
Gender: Female
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 08/31/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1004 NEWNAN RD
CARROLLTON GA
30116-6428
US

IV. Provider business mailing address

3051 LAKEVIEW PKWY
VILLA RICA GA
30180-7802
US

V. Phone/Fax

Practice location:
  • Phone: 770-836-6667
  • Fax:
Mailing address:
  • Phone: 770-783-0031
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License NumberLD002841
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: