MEDICARE: MS. JACQUELYN MARIE HENRY P.T.

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	225100000X	Physical Therapist	PT005494	GA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1528386141
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. JACQUELYN MARIE HENRY P.T.

Provider Business Mailing Address
First Line	:	5361 BROWNWOOD DRIVE
Second Line	:
City	:	POWDER SPRINGS
State	:	GA
Zip	:	30127-4719
Country	:	US
Telephone Number	:	404-849-2710
Fax Number	:

Provider Business Practice Location Address
First Line	:	5361 BROWNWOOD DRIVE
Second Line	:
City	:	POWDER SPRINGS
State	:	GA
Zip	:	30127-4719
Country	:	US
Telephone Number	:	404-849-2710
Fax Number	:

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

Provider Enumeration Date	:	05/06/2010
Last Update Date	:	05/06/2010

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