Provider Demographics
NPI:1558967869
Name:WIMBERLY, JESSICA ALYSSA
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:ALYSSA
Last Name:WIMBERLY
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 1:367 MOODY RD
Mailing Address - Street 2:
Mailing Address - City:HINESVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:31313-7307
Mailing Address - Country:US
Mailing Address - Phone:912-432-5759
Mailing Address - Fax:
Practice Address - Street 1:1718 N COASTAL HWY
Practice Address - Street 2:
Practice Address - City:MIDWAY
Practice Address - State:GA
Practice Address - Zip Code:31320-3415
Practice Address - Country:US
Practice Address - Phone:912-880-2288
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-12-10
Last Update Date:2020-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GADH012383124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist