Healthcare Provider Details

I. General information

NPI: 1003532003
Provider Name (Legal Business Name): MS. JAIME PENN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/12/2022
Last Update Date: 10/12/2022
Certification Date: 10/12/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2226 ACAPULCO DR APT C
AUGUSTA GA
30906-2376
US

IV. Provider business mailing address

PO BOX 16441
AUGUSTA GA
30919-2441
US

V. Phone/Fax

Practice location:
  • Phone: 706-750-9442
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: