Provider Demographics
NPI:1063488708
Name:SISSOM, JENNIFER B (PA)
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:B
Last Name:SISSOM
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1609 MAPMAKER DR
Mailing Address - Street 2:
Mailing Address - City:DACULA
Mailing Address - State:GA
Mailing Address - Zip Code:30019-7818
Mailing Address - Country:US
Mailing Address - Phone:404-788-4321
Mailing Address - Fax:
Practice Address - Street 1:2383 PATE ST N
Practice Address - Street 2:
Practice Address - City:SNELLVILLE
Practice Address - State:GA
Practice Address - Zip Code:30078-3250
Practice Address - Country:US
Practice Address - Phone:770-972-4845
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-02-23
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA004267363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA824570839AMedicaid
GA97WCFPRMedicare ID - Type Unspecified