Provider Demographics
NPI:1235820515
Name:GLEAVES, JESSICA ANN (COA)
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:ANN
Last Name:GLEAVES
Suffix:
Gender:F
Credentials:COA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:1100 JOHNSON FY RD NE STE 593
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30342-1733
Mailing Address - Country:US
Mailing Address - Phone:404-299-5209
Mailing Address - Fax:404-296-7415
Practice Address - Street 1:1100 JOHNSON FY RD NE STE 593
Practice Address - Street 2:
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30342-1733
Practice Address - Country:US
Practice Address - Phone:404-299-5209
Practice Address - Fax:404-296-7415
Is Sole Proprietor?:No
Enumeration Date:2023-05-17
Last Update Date:2023-05-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA311526156FX1101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156FX1101XEye and Vision Services ProvidersTechnician/TechnologistOphthalmic Assistant