Healthcare Provider Details

I. General information

NPI: 1730886268
Provider Name (Legal Business Name): JUSTIN HENRY PMHNP-BC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/15/2023
Last Update Date: 10/09/2025
Certification Date: 10/09/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1810 MULKEY RD STE 202
AUSTELL GA
30106-1150
US

IV. Provider business mailing address

29 LAKE OVERLOOK DR
WHITE GA
30184-4812
US

V. Phone/Fax

Practice location:
  • Phone: 770-694-6349
  • Fax:
Mailing address:
  • Phone: 770-490-0548
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License NumberRN222607
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: