Provider Demographics
NPI:1558853325
Name:STOCKHAM, JESSICA LYNN (FNP-C)
Entity type:Individual
Prefix:MRS
First Name:JESSICA
Middle Name:LYNN
Last Name:STOCKHAM
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 1:1001 BUCKEYE LN
Mailing Address - Street 2:
Mailing Address - City:VILLA RICA
Mailing Address - State:GA
Mailing Address - Zip Code:30180-5328
Mailing Address - Country:US
Mailing Address - Phone:706-766-1677
Mailing Address - Fax:
Practice Address - Street 1:101 DOCTORS DR
Practice Address - Street 2:
Practice Address - City:CARROLLTON
Practice Address - State:GA
Practice Address - Zip Code:30117-4486
Practice Address - Country:US
Practice Address - Phone:706-766-1677
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-06-06
Last Update Date:2019-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN236119163W00000X, 363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163W00000XNursing Service ProvidersRegistered Nurse