Provider Demographics
NPI:1669753745
Name:WILLIS, JADE NICOLE (PA-C)
Entity type:Individual
Prefix:MISS
First Name:JADE
Middle Name:NICOLE
Last Name:WILLIS
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:200 PARKBROOKE DR
Mailing Address - Street 2:SUITE 100
Mailing Address - City:WOODSTOCK
Mailing Address - State:GA
Mailing Address - Zip Code:30189-6331
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3950 AUSTELL RD # 22
Practice Address - Street 2:
Practice Address - City:AUSTELL
Practice Address - State:GA
Practice Address - Zip Code:30106-1121
Practice Address - Country:US
Practice Address - Phone:770-732-4022
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-09-02
Last Update Date:2019-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA6079363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant