Provider Demographics
NPI:1538320213
Name:FORD, JESSICA TATUM (MD)
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:TATUM
Last Name:FORD
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:550 PROFESSIONAL DR
Mailing Address - Street 2:
Mailing Address - City:MACON
Mailing Address - State:GA
Mailing Address - Zip Code:31201-1411
Mailing Address - Country:US
Mailing Address - Phone:478-741-3007
Mailing Address - Fax:478-330-6288
Practice Address - Street 1:550 PROFESSIONAL DR
Practice Address - Street 2:
Practice Address - City:MACON
Practice Address - State:GA
Practice Address - Zip Code:31201-1411
Practice Address - Country:US
Practice Address - Phone:478-741-3007
Practice Address - Fax:478-330-6288
Is Sole Proprietor?:No
Enumeration Date:2008-06-24
Last Update Date:2011-12-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA003046208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics