Healthcare Provider Details

I. General information

NPI: 1851908446
Provider Name (Legal Business Name): JADE ASANTE-SELBY NP-C
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/28/2020
Last Update Date: 08/23/2021
Certification Date: 08/23/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3027 JIM MOORE RD
DACULA GA
30019-1144
US

IV. Provider business mailing address

3027 JIM MOORE RD
DACULA GA
30019-1144
US

V. Phone/Fax

Practice location:
  • Phone: 770-339-0129
  • Fax:
Mailing address:
  • Phone: 770-339-0129
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberRN271129
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: