Basic Information
| Provider Information | |||||||||
| NPI: | 1730722489 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MENKE | ||||||||
| FirstName: | JESSICA | ||||||||
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| Credential: | FNP-C, ENP-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 777 MEMORIAL DR SE UNIT 1112 | ||||||||
| Address2: | |||||||||
| City: | ATLANTA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 303161213 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6788956278 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 80 JESSE HILL JR DR SE | ||||||||
| Address2: | |||||||||
| City: | ATLANTA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 303033031 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4046161000 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 10/25/2019 | ||||||||
| LastUpdateDate: | 02/28/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 02/28/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 163W00000X | 223118 | GA | N | Nursing Service Providers | Registered Nurse | 363L00000X | 223118 | GA | Y | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |
No ID Information.