Provider Demographics
NPI:1205445426
Name:BREAUX, JESSICA NICOLE (NP)
Entity type:Individual
Prefix:
First Name:JESSICA
Middle Name:NICOLE
Last Name:BREAUX
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 1:195 COWETA LAKE RD
Mailing Address - Street 2:
Mailing Address - City:NEWNAN
Mailing Address - State:GA
Mailing Address - Zip Code:30265-1815
Mailing Address - Country:US
Mailing Address - Phone:404-226-4836
Mailing Address - Fax:
Practice Address - Street 1:1267 HIGHWAY 54 W STE 2200
Practice Address - Street 2:
Practice Address - City:FAYETTEVILLE
Practice Address - State:GA
Practice Address - Zip Code:30214-2110
Practice Address - Country:US
Practice Address - Phone:770-716-0051
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-07-23
Last Update Date:2025-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN239680163W00000X
GAAPRN-NP239680363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA239680Medicaid