Healthcare Provider Details

I. General information

NPI: 1568865905
Provider Name (Legal Business Name): JAZELLE WILSON
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/30/2014
Last Update Date: 12/13/2025
Certification Date: 12/13/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

285 W WIEUCA RD NE # 4357
ATLANTA GA
30342-3321
US

IV. Provider business mailing address

285 W WIEUCA RD NE # 4357
ATLANTA GA
30342-3321
US

V. Phone/Fax

Practice location:
  • Phone: 470-387-9044
  • Fax:
Mailing address:
  • Phone: 470-387-9044
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License NumberMSW010930
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: