Basic Information
| Provider Information | |||||||||
| NPI: | 1457515363 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | FOSTER | ||||||||
| FirstName: | JESSICA | ||||||||
| MiddleName: | LYN | ||||||||
| NamePrefix: | MISS | ||||||||
| NameSuffix: | |||||||||
| Credential: | APRN | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3805 CHEROKEE ST NW | ||||||||
| Address2: | |||||||||
| City: | KENNESAW | ||||||||
| State: | GA | ||||||||
| PostalCode: | 301442085 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7704265666 | ||||||||
| FaxNumber: | 7704269212 | ||||||||
| Practice Location | |||||||||
| Address1: | 3805 CHEROKEE ST NW | ||||||||
| Address2: | |||||||||
| City: | KENNESAW | ||||||||
| State: | GA | ||||||||
| PostalCode: | 301442085 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7704265666 | ||||||||
| FaxNumber: | 7704269212 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/10/2008 | ||||||||
| LastUpdateDate: | 05/18/2016 | ||||||||
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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 | 363LF0000X | RN 159786 NP | GA | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
ID Information
| ID | Type | State | Issuer | Description | 874033748B | 05 | GA | MEDICAID |