Healthcare Provider Details

I. General information

NPI: 1720640287
Provider Name (Legal Business Name): JESSICA LYNN THOMAS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/05/2019
Last Update Date: 10/07/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2701 N DECATUR RD
DECATUR GA
30033-5918
US

IV. Provider business mailing address

2673 ROSEMARY ST NW
ATLANTA GA
30318-1138
US

V. Phone/Fax

Practice location:
  • Phone: 404-501-1000
  • Fax:
Mailing address:
  • Phone: 706-302-9466
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163WN0002X
TaxonomyNeonatal Intensive Care Registered Nurse
License Number217217
License Number StateGA
# 2
Primary TaxonomyY
Taxonomy Code363LN0000X
TaxonomyNeonatal Nurse Practitioner
License NumberRN217217
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: