Provider Demographics
NPI:1760795918
Name:KELLER, JESSICA TENCH (PA)
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:TENCH
Last Name:KELLER
Suffix:
Gender:F
Credentials:PA
Other - Prefix:MISS
Other - First Name:JESSICA
Other - Middle Name:NICOLE
Other - Last Name:TENCH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1439 JESSE JEWELL PKWY NE STE 302
Mailing Address - Street 2:
Mailing Address - City:GAINESVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30501-3806
Mailing Address - Country:US
Mailing Address - Phone:770-219-9200
Mailing Address - Fax:
Practice Address - Street 1:1439 JESSE JEWELL PKWY NE STE 302
Practice Address - Street 2:
Practice Address - City:GAINESVILLE
Practice Address - State:GA
Practice Address - Zip Code:30501-3806
Practice Address - Country:US
Practice Address - Phone:770-219-9200
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-07-16
Last Update Date:2020-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA005978363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical