Healthcare Provider Details

I. General information

NPI: 1356496434
Provider Name (Legal Business Name): JESSE JAMES PA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/25/2007
Last Update Date: 01/24/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

616 19TH ST
COLUMBUS GA
31901-1528
US

IV. Provider business mailing address

PO BOX 532724
ATLANTA GA
30353-2724
US

V. Phone/Fax

Practice location:
  • Phone: 904-805-1300
  • Fax: 904-805-1302
Mailing address:
  • Phone: 904-805-1300
  • Fax: 904-805-1302

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number003315
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: