Healthcare Provider Details

I. General information

NPI: 1922417641
Provider Name (Legal Business Name): JASMINE ALISHIA RUTHERFORD PSYD
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/06/2014
Last Update Date: 08/06/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

17 FELTON PL SUITE A
CARTERSVILLE GA
30120-2153
US

IV. Provider business mailing address

17 FELTON PL SUITE A
CARTERSVILLE GA
30120-2153
US

V. Phone/Fax

Practice location:
  • Phone: 770-386-8996
  • Fax: 770-386-8100
Mailing address:
  • Phone: 770-386-8996
  • Fax: 770-386-8100

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License NumberPSY003814
License Number StateGA

VIII. Authorized Official

Name: MRS. MARIA VICTORIA MCMICKENS
Title or Position: BUSINESS MANAGER
Credential:
Phone: 770-386-8996