Provider Demographics
NPI:1083227821
Name:RETTERBUSH, JESSICA SENFT (PA-C)
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:SENFT
Last Name:RETTERBUSH
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1100 WESTBROOKE WAY NE
Mailing Address - Street 2:
Mailing Address - City:BROOKHAVEN
Mailing Address - State:GA
Mailing Address - Zip Code:30319-4805
Mailing Address - Country:US
Mailing Address - Phone:404-617-9797
Mailing Address - Fax:
Practice Address - Street 1:1015 MANSELL RD
Practice Address - Street 2:
Practice Address - City:ROSWELL
Practice Address - State:GA
Practice Address - Zip Code:30076-1507
Practice Address - Country:US
Practice Address - Phone:770-521-2229
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-08-30
Last Update Date:2023-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA9897363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant