Healthcare Provider Details

I. General information

NPI: 1790283885
Provider Name (Legal Business Name): JALISA BRIANNA BENJAMIN FNP-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/24/2018
Last Update Date: 09/02/2026
Certification Date: 09/02/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

212 HOSPITAL DR # DE
WASHINGTON GA
30673-5619
US

IV. Provider business mailing address

872 FLETCHER STANLEY RD
MONTROSE GA
31065-3310
US

V. Phone/Fax

Practice location:
  • Phone: 706-678-6944
  • Fax:
Mailing address:
  • Phone: 478-290-7248
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberAPRN-NP307032
License Number StateGA
# 2
Primary TaxonomyN
Taxonomy Code164W00000X
TaxonomyLicensed Practical Nurse
License NumberLPN094885
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: