MEDICARE: MRS. JACQUELYN T. FOSTER PA

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363AS0400X	Surgical Physician Assistant	001688	GA

General Provider Information

NPI Number	:	1730368085
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. JACQUELYN T. FOSTER PA

Provider Business Mailing Address
First Line	:	1271 POUNDS LN
Second Line	:
City	:	CLARKSTON
State	:	GA
Zip	:	30021-2830
Country	:	US
Telephone Number	:	404-616-1415
Fax Number	:	404-616-1417

Provider Business Practice Location Address
First Line	:	720 WESTVIEW DR SW
Second Line	:
City	:	ATLANTA
State	:	GA
Zip	:	30310-1458
Country	:	US
Telephone Number	:	404-616-1415
Fax Number	:	404-616-1417

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	11/02/2007
Last Update Date	:	11/02/2007

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