MEDICARE: JEFFREY POLK

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	101YM0800X	Mental Health Counselor

General Provider Information

NPI Number	:	1861013336
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JEFFREY POLK

Provider Business Mailing Address
First Line	:	4408 CLEMENT DR SW
Second Line	:
City	:	ATLANTA
State	:	GA
Zip	:	30331-4516
Country	:	US
Telephone Number	:	404-673-9992
Fax Number	:

Provider Business Practice Location Address
First Line	:	4408 CLEMENT DR SW
Second Line	:
City	:	ATLANTA
State	:	GA
Zip	:	30331-4516
Country	:	US
Telephone Number	:	404-673-9992
Fax Number	:

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

Provider Enumeration Date	:	05/06/2020
Last Update Date	:	05/06/2020

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Directions to “ JEFFREY POLK ” Practice Location

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