Provider Demographics
NPI:1245985886
Name:BROTH, JESSICA (FNP-C)
Entity type:Individual
Prefix:
First Name:JESSICA
Middle Name:
Last Name:BROTH
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 1:1506 KLONDIKE RD SW STE 205
Mailing Address - Street 2:
Mailing Address - City:CONYERS
Mailing Address - State:GA
Mailing Address - Zip Code:30094-5173
Mailing Address - Country:US
Mailing Address - Phone:678-750-4000
Mailing Address - Fax:678-750-4005
Practice Address - Street 1:1506 KLONDIKE RD SW STE 205
Practice Address - Street 2:
Practice Address - City:CONYERS
Practice Address - State:GA
Practice Address - Zip Code:30094-5173
Practice Address - Country:US
Practice Address - Phone:678-750-4000
Practice Address - Fax:678-750-4005
Is Sole Proprietor?:No
Enumeration Date:2022-02-12
Last Update Date:2023-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GALC000233163WL0100X
GARN175180363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163WL0100XNursing Service ProvidersRegistered NurseLactation Consultant
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA003269528DMedicaid