Provider Demographics
NPI:1275269490
Name:STREET, JESSIE ANN (MED)
Entity Type:Individual
Prefix:
First Name:JESSIE
Middle Name:ANN
Last Name:STREET
Suffix:
Gender:F
Credentials:MED
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3022 BLANDWOOD RD
Mailing Address - Street 2:
Mailing Address - City:VALDOSTA
Mailing Address - State:GA
Mailing Address - Zip Code:31602-1314
Mailing Address - Country:US
Mailing Address - Phone:404-654-7747
Mailing Address - Fax:
Practice Address - Street 1:3022 BLANDWOOD RD
Practice Address - Street 2:
Practice Address - City:VALDOSTA
Practice Address - State:GA
Practice Address - Zip Code:31602-1314
Practice Address - Country:US
Practice Address - Phone:404-654-7747
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-07-29
Last Update Date:2022-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator