Provider Demographics
NPI:1417603598
Name:DOUGLAS, JODIAN KEDOYA
Entity Type:Individual
Prefix:
First Name:JODIAN
Middle Name:KEDOYA
Last Name:DOUGLAS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5621 WASHAKIE PT
Mailing Address - Street 2:
Mailing Address - City:ELLENWOOD
Mailing Address - State:GA
Mailing Address - Zip Code:30294-6691
Mailing Address - Country:US
Mailing Address - Phone:678-328-9884
Mailing Address - Fax:
Practice Address - Street 1:80 JESSE HILL JR DR SE
Practice Address - Street 2:
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30303-3031
Practice Address - Country:US
Practice Address - Phone:404-616-1000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-02-27
Last Update Date:2024-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN236711163W00000X, 363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No163W00000XNursing Service ProvidersRegistered Nurse