=====================================================
General NPI Number Information
=====================================================
NPI Number | 1154848182
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JEFF R. JEAN FNP-BC
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/30/2017
-----------------------------------------------------
Last Update Date | 10/29/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1364 CLIFTON RD NE
-----------------------------------------------------
City | ATLANTA
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30322-1059
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 404-712-7109
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2548 WALNUT RIDGE WAY
-----------------------------------------------------
City | STOCKBRIDGE
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30281-9214
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 678-876-7880
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363L00000X
-----------------------------------------------------
Taxonomy Name | Nurse Practitioner
-----------------------------------------------------
License Number | APRN-NP179648
-----------------------------------------------------
License Number State | GA
-----------------------------------------------------