Healthcare Provider Details

I. General information

NPI: 1992379135
Provider Name (Legal Business Name): JESSICA LAURYN BAUM PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/13/2021
Last Update Date: 01/24/2025
Certification Date: 01/24/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

631 PROFESSIONAL DR STE 170
LAWRENCEVILLE GA
30046-3392
US

IV. Provider business mailing address

631 PROFESSIONAL DR STE 170
LAWRENCEVILLE GA
30046-3392
US

V. Phone/Fax

Practice location:
  • Phone: 678-612-2663
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207XX0801X
TaxonomyOrthopaedic Trauma Physician
License Number10351
License Number StateGA
# 2
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number10351
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: