Healthcare Provider Details

I. General information

NPI: 1053413963
Provider Name (Legal Business Name): JACQUELINE IRWIN LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/01/2006
Last Update Date: 08/13/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1493 LAVISTA RD NE
ATLANTA GA
30324-3846
US

IV. Provider business mailing address

2281 BRIANWOOD TRL
DECATUR GA
30033-1719
US

V. Phone/Fax

Practice location:
  • Phone: 404-667-7267
  • Fax:
Mailing address:
  • Phone: 404-667-7267
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberCSW000334
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: