Healthcare Provider Details

I. General information

NPI: 1790248771
Provider Name (Legal Business Name): JERONIA BOWDEN LMSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/08/2019
Last Update Date: 10/25/2021
Certification Date: 10/25/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

794 TIFT AVE SW
ATLANTA GA
30310-2834
US

IV. Provider business mailing address

3807 CLAIRMONT RD
CHAMBLEE GA
30341-4911
US

V. Phone/Fax

Practice location:
  • Phone: 404-401-7647
  • Fax:
Mailing address:
  • Phone: 770-457-5867
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License NumberMSW007375
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: