Individual
JENNIFER ROBIN VISTNES
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
F
Credential
O.T.
Contact information
Practice address
318 W PIKE ST, SUITE 104, LAWRENCEVILLE, GA 30045-3234
(678) 377-2833
(678) 377-2882
Mailing address
4521 SHILOH RD, LOGANVILLE, GA 30052-3551
(770) 554-5896
(770) 554-8146
Taxonomy
Speciality
Code
Description
License number
State
225X00000X
Occupational Therapist
Primary
002800
GA
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
00840804B
—
GA
01
—
10037643
AMERIGROUP PROVIDER NUMBE
GA
01
—
307939
WELLCARE PROVIDER NUMBER
GA
Enumeration date
12/18/2006
Last updated
07/09/2007
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