Provider Demographics
NPI:1780659474
Name:WASSERMAN, JESSICA L (NP)
Entity Type:Individual
Prefix:MS
First Name:JESSICA
Middle Name:L
Last Name:WASSERMAN
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1190 STANDARD DR NE
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30319-3353
Mailing Address - Country:US
Mailing Address - Phone:508-450-6645
Mailing Address - Fax:
Practice Address - Street 1:TOWER MEDICAL OFFICE BLDG
Practice Address - Street 2:5670 PEACHTREE RD SUITE 1000
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30342
Practice Address - Country:US
Practice Address - Phone:404-255-1930
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-02-17
Last Update Date:2007-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA237102363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAQ46773Medicare UPIN