Healthcare Provider Details

I. General information

NPI: 1528982303
Provider Name (Legal Business Name): JESIKA OLGUIN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/05/2026
Last Update Date: 08/05/2026
Certification Date: 08/05/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

605 BEAVER RUIN RD NW STE A
LILBURN GA
30047-3430
US

IV. Provider business mailing address

335 HARTWELL DR
LAWRENCEVILLE GA
30043-3567
US

V. Phone/Fax

Practice location:
  • Phone: 478-444-8651
  • Fax:
Mailing address:
  • Phone: 678-768-3206
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License NumberAPRNNP260046
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: