Provider Demographics
NPI:1558051888
Name:GAYDOS, JESSICA ASHLEY
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:ASHLEY
Last Name:GAYDOS
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 1:1407 CHATLEY WAY
Mailing Address - Street 2:
Mailing Address - City:WOODSTOCK
Mailing Address - State:GA
Mailing Address - Zip Code:30188-5533
Mailing Address - Country:US
Mailing Address - Phone:912-230-2656
Mailing Address - Fax:
Practice Address - Street 1:191 S MARIETTA PKWY SW
Practice Address - Street 2:
Practice Address - City:MARIETTA
Practice Address - State:GA
Practice Address - Zip Code:30064-3291
Practice Address - Country:US
Practice Address - Phone:404-939-4979
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-05-10
Last Update Date:2023-05-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN257235163W00000X, 363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163W00000XNursing Service ProvidersRegistered Nurse