Healthcare Provider Details

I. General information

NPI: 1649249285
Provider Name (Legal Business Name): JESSICA HUNTER MATHIS NPC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/16/2006
Last Update Date: 09/26/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1007 GREENFIELD DR
TIFTON GA
31794-3795
US

IV. Provider business mailing address

907 18TH ST E SUITE 150
TIFTON GA
31794-3643
US

V. Phone/Fax

Practice location:
  • Phone: 229-382-9733
  • Fax: 229-387-6161
Mailing address:
  • Phone: 229-382-9733
  • Fax: 229-387-6161

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LA2100X
TaxonomyAcute Care Nurse Practitioner
License NumberRN142973NP
License Number StateGA
# 2
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberRN142973
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: