Provider Demographics
NPI:1902871965
Name:HART, JESSICA LYNN (PA C)
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:LYNN
Last Name:HART
Suffix:
Gender:F
Credentials:PA C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:907 18TH ST E
Mailing Address - Street 2:SUITE 490
Mailing Address - City:TIFTON
Mailing Address - State:GA
Mailing Address - Zip Code:31794-3643
Mailing Address - Country:US
Mailing Address - Phone:229-391-3320
Mailing Address - Fax:
Practice Address - Street 1:907 18TH ST E
Practice Address - Street 2:SUITE 490
Practice Address - City:TIFTON
Practice Address - State:GA
Practice Address - Zip Code:31794-3643
Practice Address - Country:US
Practice Address - Phone:229-391-3320
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-02-22
Last Update Date:2010-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA003928363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA769232411CMedicaid
GA769232411DMedicaid
P93918Medicare UPIN
97WCDXJMedicare ID - Type Unspecified