Healthcare Provider Details

I. General information

NPI: 1376454207
Provider Name (Legal Business Name): MARVALENE ROSLYNN JACK
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/17/2026
Last Update Date: 09/17/2026
Certification Date: 09/17/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

PO BOX 82516
CONYERS GA
30013-9437
US

IV. Provider business mailing address

103 SALEM GLEN WAY SE
CONYERS GA
30013-5323
US

V. Phone/Fax

Practice location:
  • Phone: 470-227-5653
  • Fax:
Mailing address:
  • Phone: 470-227-5653
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License NumberMT014691
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: