Provider Demographics
NPI:1669837365
Name:PETERSON, JASMINE (PA)
Entity Type:Individual
Prefix:
First Name:JASMINE
Middle Name:
Last Name:PETERSON
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:1525 CLIFTON RD NE
Mailing Address - Street 2:FL 4
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30322-4200
Mailing Address - Country:US
Mailing Address - Phone:706-322-9599
Mailing Address - Fax:706-507-3047
Practice Address - Street 1:1600 FORT BENNING RD
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:GA
Practice Address - Zip Code:31903-2834
Practice Address - Country:US
Practice Address - Phone:706-322-9599
Practice Address - Fax:706-507-3047
Is Sole Proprietor?:No
Enumeration Date:2015-12-22
Last Update Date:2021-10-14
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
GA7914363A00000X
363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant