Provider Demographics
NPI:1770795361
Name:MATTINGLY, JILL RAE (PA-C, MMSC)
Entity type:Individual
Prefix:
First Name:JILL
Middle Name:RAE
Last Name:MATTINGLY
Suffix:
Gender:F
Credentials:PA-C, MMSC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:586 MOUNTAIN PARK TRL
Mailing Address - Street 2:
Mailing Address - City:STONE MOUNTAIN
Mailing Address - State:GA
Mailing Address - Zip Code:30087-5709
Mailing Address - Country:US
Mailing Address - Phone:770-469-6903
Mailing Address - Fax:
Practice Address - Street 1:4500 HUGH HOWELL RD
Practice Address - Street 2:SUITE 340
Practice Address - City:TUCKER
Practice Address - State:GA
Practice Address - Zip Code:30084-4723
Practice Address - Country:US
Practice Address - Phone:678-534-1715
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-04
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA3283363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant