Provider Demographics
NPI:1720608870
Name:DOCKHAM, JESSICA CATHERINE (PA-C)
Entity type:Individual
Prefix:MRS
First Name:JESSICA
Middle Name:CATHERINE
Last Name:DOCKHAM
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:MS
Other - First Name:JESSICA
Other - Middle Name:CATHERINE
Other - Last Name:GAUDIOSI
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:3747 ROSWELL RD STE 201
Mailing Address - Street 2:
Mailing Address - City:MARIETTA
Mailing Address - State:GA
Mailing Address - Zip Code:30062-6227
Mailing Address - Country:US
Mailing Address - Phone:470-956-1590
Mailing Address - Fax:770-971-8499
Practice Address - Street 1:3747 ROSWELL RD STE 201
Practice Address - Street 2:
Practice Address - City:MARIETTA
Practice Address - State:GA
Practice Address - Zip Code:30062-6227
Practice Address - Country:US
Practice Address - Phone:470-956-1590
Practice Address - Fax:770-971-8499
Is Sole Proprietor?:No
Enumeration Date:2020-04-19
Last Update Date:2023-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NH1611363A00000X
GA11608363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NH3123219Medicaid