Provider Demographics
NPI:1235695081
Name:WYSOCK, JESSICA (AGACNP)
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:
Last Name:WYSOCK
Suffix:
Gender:F
Credentials:AGACNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1400 NORTHSIDE FORSYTH DR STE 310
Mailing Address - Street 2:
Mailing Address - City:CUMMING
Mailing Address - State:GA
Mailing Address - Zip Code:30041-6017
Mailing Address - Country:US
Mailing Address - Phone:678-845-7300
Mailing Address - Fax:678-845-7301
Practice Address - Street 1:1400 NORTHSIDE FORSYTH DR STE 310
Practice Address - Street 2:
Practice Address - City:CUMMING
Practice Address - State:GA
Practice Address - Zip Code:30041-6017
Practice Address - Country:US
Practice Address - Phone:678-845-7300
Practice Address - Fax:678-845-7301
Is Sole Proprietor?:No
Enumeration Date:2019-02-18
Last Update Date:2019-02-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN277050363LA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care