Provider Demographics
NPI:1891760757
Name:JACKONISKI, DEVON NOBIS (PA)
Entity Type:Individual
Prefix:
First Name:DEVON
Middle Name:NOBIS
Last Name:JACKONISKI
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:DEVON
Other - Middle Name:
Other - Last Name:NOBIS
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:PA
Mailing Address - Street 1:5671 PEACHTREE DUNWOODY RD NE
Mailing Address - Street 2:SUITE 700
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30342-5000
Mailing Address - Country:US
Mailing Address - Phone:404-847-9999
Mailing Address - Fax:404-531-8466
Practice Address - Street 1:5671 PEACHTREE DUNWOODY RD NE
Practice Address - Street 2:SUITE 700
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30342-5000
Practice Address - Country:US
Practice Address - Phone:404-847-9999
Practice Address - Fax:404-531-8466
Is Sole Proprietor?:No
Enumeration Date:2006-02-22
Last Update Date:2010-05-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA003657363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant