Provider Demographics
NPI:1790982361
Name:KOBLEUR, JESSICA AGNES (MD)
Entity Type:Individual
Prefix:DR
First Name:JESSICA
Middle Name:AGNES
Last Name:KOBLEUR
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
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Other - Middle Name:
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Mailing Address - Street 1:PO BOX 658
Mailing Address - Street 2:
Mailing Address - City:GAINESVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30503-0658
Mailing Address - Country:US
Mailing Address - Phone:770-533-6511
Mailing Address - Fax:770-533-4786
Practice Address - Street 1:743 SPRING ST NE
Practice Address - Street 2:
Practice Address - City:GAINESVILLE
Practice Address - State:GA
Practice Address - Zip Code:30501-3715
Practice Address - Country:US
Practice Address - Phone:770-535-3611
Practice Address - Fax:770-535-7092
Is Sole Proprietor?:No
Enumeration Date:2007-06-28
Last Update Date:2019-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC29977208000000X
GA064662208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCGA1079Medicaid
GA731872400DMedicaid
GAP01069469OtherRAILROAD MEDICARE
GA731872400BMedicaid