Provider Demographics
NPI:1245871763
Name:COBURN, JESSICA R (FNP-C)
Entity type:Individual
Prefix:MRS
First Name:JESSICA
Middle Name:R
Last Name:COBURN
Suffix:
Gender:F
Credentials:FNP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1452 CHESTER HARRIS DR N
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:GA
Mailing Address - Zip Code:30132-0368
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:100 MARKET PLACE BLVD STE 301
Practice Address - Street 2:
Practice Address - City:CARTERSVILLE
Practice Address - State:GA
Practice Address - Zip Code:30121-8717
Practice Address - Country:US
Practice Address - Phone:678-290-4817
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-10-06
Last Update Date:2024-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC23255363LF0000X
GARN330929363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCPG1120Medicaid