Provider Demographics
NPI:1427644640
Name:BASTECKI, JENNIFER MICHELLE (FNP-C)
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:MICHELLE
Last Name:BASTECKI
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 1:350 LA PERLA DR
Mailing Address - Street 2:
Mailing Address - City:SUGAR HILL
Mailing Address - State:GA
Mailing Address - Zip Code:30518-6161
Mailing Address - Country:US
Mailing Address - Phone:770-366-8853
Mailing Address - Fax:
Practice Address - Street 1:11459 JOHNS CREEK PKWY STE 250
Practice Address - Street 2:
Practice Address - City:DULUTH
Practice Address - State:GA
Practice Address - Zip Code:30097-3517
Practice Address - Country:US
Practice Address - Phone:770-497-1555
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-12-13
Last Update Date:2020-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN223372363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily