MEDICARE: TERESA ANN JONES WILDER CD, PCD, CBC,RPYT85

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	374J00000X	Doula		GA
2	171400000X	Health & Wellness Coach		GA

General Provider Information

NPI Number	:	1750098984
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	TERESA ANN JONES WILDER CD, PCD, CBC,RPYT85

Provider Business Mailing Address
First Line	:	772 POINTE SOUTH PKWY APT 1903
Second Line	:
City	:	JONESBORO
State	:	GA
Zip	:	30238-4314
Country	:	US
Telephone Number	:	404-713-5807
Fax Number	:

Provider Business Practice Location Address
First Line	:	772 POINTE SOUTH PKWY APT 1903
Second Line	:
City	:	JONESBORO
State	:	GA
Zip	:	30238-4314
Country	:	US
Telephone Number	:	404-713-5807
Fax Number	:

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

Provider Enumeration Date	:	10/27/2022
Last Update Date	:	10/27/2022

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