Provider Demographics
NPI:1942716840
Name:NIEVES, JESSICA LEANN (PA)
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:LEANN
Last Name:NIEVES
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:304 COBBLESTONE BLVD
Mailing Address - Street 2:
Mailing Address - City:STOCKBRIDGE
Mailing Address - State:GA
Mailing Address - Zip Code:30281-7306
Mailing Address - Country:US
Mailing Address - Phone:334-791-7930
Mailing Address - Fax:
Practice Address - Street 1:165 N PARK TRL
Practice Address - Street 2:
Practice Address - City:STOCKBRIDGE
Practice Address - State:GA
Practice Address - Zip Code:30281
Practice Address - Country:US
Practice Address - Phone:770-506-1800
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-12-14
Last Update Date:2019-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA008628363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant