Healthcare Provider Details

I. General information

NPI: 1053249862
Provider Name (Legal Business Name): JAQUELYNN FAASS LMSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/12/2026
Last Update Date: 05/12/2026
Certification Date: 05/12/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

219 W DAVIS ST
DECATUR GA
30030-5219
US

IV. Provider business mailing address

219 W DAVIS ST
DECATUR GA
30030-5219
US

V. Phone/Fax

Practice location:
  • Phone: 678-499-0600
  • Fax:
Mailing address:
  • Phone: 678-499-0600
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberMSW010309
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: