Healthcare Provider Details

I. General information

NPI: 1164338190
Provider Name (Legal Business Name): JORDAN AALIYAH WOOTEN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/20/2026
Last Update Date: 08/20/2026
Certification Date: 08/14/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1001 RESEARCH CENTER DR SW
ATLANTA GA
30331
US

IV. Provider business mailing address

3890 FLOYD RD APT 1307
AUSTELL GA
30106-1520
US

V. Phone/Fax

Practice location:
  • Phone: 404-691-0304
  • Fax:
Mailing address:
  • Phone: 478-321-1408
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License NumberPCET004428
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: