Basic Information
| Provider Information | |||||||||
| NPI: | 1437124385 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | KOPACKA | ||||||||
| FirstName: | JEANNE | ||||||||
| MiddleName: | L. | ||||||||
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| Credential: | PA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5671 PEACHTREE DUNWOODY RD NE | ||||||||
| Address2: | SUITE 700 | ||||||||
| City: | ATLANTA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 303425000 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4048479999 | ||||||||
| FaxNumber: | 4045318466 | ||||||||
| Practice Location | |||||||||
| Address1: | 2000 HOWARD FARM DR STE 200 | ||||||||
| Address2: | |||||||||
| City: | CUMMING | ||||||||
| State: | GA | ||||||||
| PostalCode: | 300416081 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7702926500 | ||||||||
| FaxNumber: | 7702926535 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/22/2006 | ||||||||
| LastUpdateDate: | 08/29/2019 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | 002005 | GA | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
ID Information
| ID | Type | State | Issuer | Description | 806351077B | 05 | GA | MEDICAID | 806351077A | 05 | GA | MEDICAID |