Healthcare Provider Details

I. General information

NPI: 1720608870
Provider Name (Legal Business Name): JESSICA CATHERINE DOCKHAM PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: JESSICA CATHERINE GAUDIOSI PA-C

II. Dates (important events)

Enumeration Date: 04/19/2020
Last Update Date: 09/06/2023
Certification Date: 09/06/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3747 ROSWELL RD STE 201
MARIETTA GA
30062-6227
US

IV. Provider business mailing address

3747 ROSWELL RD STE 201
MARIETTA GA
30062-6227
US

V. Phone/Fax

Practice location:
  • Phone: 470-956-1590
  • Fax: 770-971-8499
Mailing address:
  • Phone: 470-956-1590
  • Fax: 770-971-8499

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number1611
License Number StateNH
# 2
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number11608
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: