Healthcare Provider Details

I. General information

NPI: 1336870765
Provider Name (Legal Business Name): JESSICA ANNE BANKS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/17/2022
Last Update Date: 07/01/2026
Certification Date: 07/01/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

611 E VILLANOW ST
LA FAYETTE GA
30728-2618
US

IV. Provider business mailing address

615 E VILLANOW ST
LA FAYETTE GA
30728-2618
US

V. Phone/Fax

Practice location:
  • Phone: 706-638-1606
  • Fax: 706-638-9987
Mailing address:
  • Phone: 706-638-1606
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number31850
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: