Healthcare Provider Details

I. General information

NPI: 1437124385
Provider Name (Legal Business Name): JEANNE L. KOPACKA PA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/22/2006
Last Update Date: 08/29/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2000 HOWARD FARM DR STE 200
CUMMING GA
30041-6081
US

IV. Provider business mailing address

5671 PEACHTREE DUNWOODY RD NE SUITE 700
ATLANTA GA
30342-5000
US

V. Phone/Fax

Practice location:
  • Phone: 770-292-6500
  • Fax: 770-292-6535
Mailing address:
  • Phone: 404-847-9999
  • Fax: 404-531-8466

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number002005
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: