Healthcare Provider Details

I. General information

NPI: 1043130933
Provider Name (Legal Business Name): JESSICA NGUYEN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/20/2026
Last Update Date: 07/20/2026
Certification Date: 06/28/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1967 JESSE JEWELL PKWY NE
GAINESVILLE GA
30501
US

IV. Provider business mailing address

953 SIENNA RDG
BRASELTON GA
30517-3493
US

V. Phone/Fax

Practice location:
  • Phone: 678-347-1165
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License NumberOT009129
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: