Healthcare Provider Details

I. General information

NPI: 1891393005
Provider Name (Legal Business Name): JUBILEE PRIMARY CARE PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/12/2020
Last Update Date: 10/30/2020
Certification Date: 10/30/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3312 HEATHCHASE LN
SUWANEE GA
30024-4639
US

IV. Provider business mailing address

2090 LAWRENCEVILLE SUWANEE RD SUITE A#519
SUWANEE GA
30024
US

V. Phone/Fax

Practice location:
  • Phone: 678-783-4860
  • Fax: 678-940-0509
Mailing address:
  • Phone: 678-783-4860
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207QA0401X
TaxonomyAddiction Medicine (Family Medicine) Physician
License Number
License Number State

VIII. Authorized Official

Name: AVRIL PATRICE DAISLEY SHONGO
Title or Position: PROVIDER
Credential: MD
Phone: 678-783-4860