Healthcare Provider Details

I. General information

NPI: 1205936465
Provider Name (Legal Business Name): JENNIFER BUNDRICK SWALES PH.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: JENNIFER DIANE BUNDRICK PH.D.

II. Dates (important events)

Enumeration Date: 09/25/2006
Last Update Date: 01/31/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1827 POWERS FERRY RD SE BUILDING 22, SUITE 200
ATLANTA GA
30339-5621
US

IV. Provider business mailing address

1827 POWERS FERRY RD SE BUILDING 22, SUITE 200
ATLANTA GA
30339-5621
US

V. Phone/Fax

Practice location:
  • Phone: 770-953-4744
  • Fax: 770-953-4640
Mailing address:
  • Phone: 770-953-4744
  • Fax: 770-953-4640

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number33200
License Number StateTX
# 2
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number3152
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: