Healthcare Provider Details

I. General information

NPI: 1801374426
Provider Name (Legal Business Name): JESSICA ALLY WILSON ATKINS ATC, LAT, DPT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/06/2018
Last Update Date: 02/20/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2227 US HIGHWAY 41 N
TIFTON GA
31794-2749
US

IV. Provider business mailing address

2227 US HIGHWAY 41 NORTH
TIFTON GA
31794-1563
US

V. Phone/Fax

Practice location:
  • Phone: 229-353-7400
  • Fax:
Mailing address:
  • Phone: 404-998-6216
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License NumberPT013769
License Number StateGA
# 2
Primary TaxonomyN
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License NumberAT002824
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: