Provider Demographics
NPI:1962208694
Name:JAKES, AGNES REENE
Entity type:Individual
Prefix:
First Name:AGNES
Middle Name:REENE
Last Name:JAKES
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:500 PIKE DR
Mailing Address - Street 2:
Mailing Address - City:ELLERSLIE
Mailing Address - State:GA
Mailing Address - Zip Code:31807-5548
Mailing Address - Country:US
Mailing Address - Phone:706-593-5539
Mailing Address - Fax:
Practice Address - Street 1:500 PIKE DR
Practice Address - Street 2:
Practice Address - City:ELLERSLIE
Practice Address - State:GA
Practice Address - Zip Code:31807-5548
Practice Address - Country:US
Practice Address - Phone:706-593-5539
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-02-24
Last Update Date:2025-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN306752363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health