Basic Information
Provider Information | |||||||||
NPI: | 1972914497 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | COURSON | ||||||||
FirstName: | JESSICA | ||||||||
MiddleName: | LYNNE | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | NP-C | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 1111 GLYNCO PARKWAY | ||||||||
Address2: | BLDG1 STE 10 | ||||||||
City: | BRUNSWICK | ||||||||
State: | GA | ||||||||
PostalCode: | 31525 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9122649111 | ||||||||
FaxNumber: | 9122626909 | ||||||||
Practice Location | |||||||||
Address1: | 903 WEST WARD STREET | ||||||||
Address2: | SUITE B | ||||||||
City: | DOUGLAS | ||||||||
State: | GA | ||||||||
PostalCode: | 31533 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9122601191 | ||||||||
FaxNumber: | 9122601193 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 05/19/2014 | ||||||||
LastUpdateDate: | 05/19/2014 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | RN190877 | GA | Y |   | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
No ID Information.