Provider Demographics
NPI:1639303415
Name:KANG, JESSICA VIVIAN (DO)
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:VIVIAN
Last Name:KANG
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:JESSICA
Other - Middle Name:VIVIAN
Other - Last Name:PATE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DO
Mailing Address - Street 1:6602 WATERS AVE BLDG A
Mailing Address - Street 2:
Mailing Address - City:SAVANNAH
Mailing Address - State:GA
Mailing Address - Zip Code:31406-2778
Mailing Address - Country:US
Mailing Address - Phone:912-350-6000
Mailing Address - Fax:912-350-6001
Practice Address - Street 1:6602 WATERS AVE
Practice Address - Street 2:BLDG A
Practice Address - City:SAVANNAH
Practice Address - State:GA
Practice Address - Zip Code:31406-2758
Practice Address - Country:US
Practice Address - Phone:912-350-6000
Practice Address - Fax:912-350-6001
Is Sole Proprietor?:No
Enumeration Date:2009-05-08
Last Update Date:2022-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA068266207R00000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA003127368BMedicaid
GAPENDINGMedicaid
GAPENDINGMedicare UPIN
GA202I115563Medicare PIN