Provider Demographics
NPI:1649249285
Name:MATHIS, JESSICA HUNTER (NPC)
Entity type:Individual
Prefix:
First Name:JESSICA
Middle Name:HUNTER
Last Name:MATHIS
Suffix:
Gender:F
Credentials:NPC
Other - Prefix:
Other - First Name:
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Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:907 18TH ST E
Mailing Address - Street 2:SUITE 150
Mailing Address - City:TIFTON
Mailing Address - State:GA
Mailing Address - Zip Code:31794-3643
Mailing Address - Country:US
Mailing Address - Phone:229-382-9733
Mailing Address - Fax:229-387-6161
Practice Address - Street 1:1007 GREENFIELD DR
Practice Address - Street 2:
Practice Address - City:TIFTON
Practice Address - State:GA
Practice Address - Zip Code:31794-3795
Practice Address - Country:US
Practice Address - Phone:229-382-9733
Practice Address - Fax:229-387-6161
Is Sole Proprietor?:No
Enumeration Date:2006-03-16
Last Update Date:2014-09-26
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
GARN142973NP363LA2100X
GARN142973363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA50BBHHDMedicare ID - Type UnspecifiedMEDICARE PROVIDER NUMBER
GAQ11375Medicare UPIN