MEDICARE: DR. JOVANNA OMARI WILSON GAINES LCSW

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1041C0700X	Clinical Social Worker	070002-1	NY
2	1041C0700X	Clinical Social Worker	7893	OK
3	1041C0700X	Clinical Social Worker	070002	NY

General Provider Information

NPI Number	:	1407830615
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. JOVANNA OMARI WILSON GAINES LCSW

Provider Business Mailing Address
First Line	:	3278 MITCHELL BLVD
Second Line	:
City	:	MOODY AFB
State	:	GA
Zip	:	31699
Country	:	US
Telephone Number	:	910-425-4443
Fax Number	:

Provider Business Practice Location Address
First Line	:	3278 MITCHELL BLVD
Second Line	:
City	:	MOODY AFB
State	:	GA
Zip	:	31699
Country	:	US
Telephone Number	:	910-394-4700
Fax Number	:	910-394-4711

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	12/01/2005
Last Update Date	:	08/28/2023

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