Healthcare Provider Details

I. General information

NPI: 1609322197
Provider Name (Legal Business Name): JESSICA MICHELLE SHEPPARD PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/25/2016
Last Update Date: 08/22/2023
Certification Date: 08/22/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1557 JANMAR RD
SNELLVILLE GA
30078-5686
US

IV. Provider business mailing address

1551 JANMAR RD
SNELLVILLE GA
30078-5606
US

V. Phone/Fax

Practice location:
  • Phone: 678-344-8900
  • Fax:
Mailing address:
  • Phone: 678-344-8900
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number9109650
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number9204
License Number StateGA
# 3
Primary TaxonomyN
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License Number
License Number State
# 4
Primary TaxonomyY
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License Number9204
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: