Healthcare Provider Details

I. General information

NPI: 1699545822
Provider Name (Legal Business Name): JODY MILFORD BAHAM FNP-BC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/08/2024
Last Update Date: 10/09/2025
Certification Date: 10/09/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

138 CANAL ST STE 201
POOLER GA
31322-4047
US

IV. Provider business mailing address

413 GRAVEL WAY
BLOOMINGDALE GA
31302-8120
US

V. Phone/Fax

Practice location:
  • Phone: 912-348-3383
  • Fax: 912-348-2669
Mailing address:
  • Phone: 706-599-7174
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberRN287159
License Number StateGA
# 2
Primary TaxonomyN
Taxonomy Code207QB0002X
TaxonomyObesity Medicine (Family Medicine) Physician
License NumberRN287159
License Number StateGA
# 3
Primary TaxonomyN
Taxonomy Code207QA0401X
TaxonomyAddiction Medicine (Family Medicine) Physician
License NumberRN287159
License Number StateGA
# 4
Primary TaxonomyN
Taxonomy Code261QP3300X
TaxonomyPain Clinic/Center
License NumberRN287159
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: