Provider Demographics
NPI:1093128621
Name:WEGMANN, JESSICA (CSFA)
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:
Last Name:WEGMANN
Suffix:
Gender:F
Credentials:CSFA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 16957
Mailing Address - Street 2:
Mailing Address - City:SAVANNAH
Mailing Address - State:GA
Mailing Address - Zip Code:31416-3657
Mailing Address - Country:US
Mailing Address - Phone:912-303-6678
Mailing Address - Fax:912-355-3066
Practice Address - Street 1:5205 FREDERICK ST STE A
Practice Address - Street 2:
Practice Address - City:SAVANNAH
Practice Address - State:GA
Practice Address - Zip Code:31405-4520
Practice Address - Country:US
Practice Address - Phone:912-303-6678
Practice Address - Fax:912-355-3066
Is Sole Proprietor?:Yes
Enumeration Date:2014-06-11
Last Update Date:2015-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA149391246ZC0007X
GA363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
No246ZC0007XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, OtherSurgical Assistant