Healthcare Provider Details

I. General information

NPI: 1669191714
Provider Name (Legal Business Name): JEREMY SAWYERS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/23/2022
Last Update Date: 09/22/2022
Certification Date: 09/22/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

445 WINN WAY
DECATUR GA
30030-1707
US

IV. Provider business mailing address

445 WINN WAY
DECATUR GA
30030-1707
US

V. Phone/Fax

Practice location:
  • Phone: 404-508-7700
  • Fax:
Mailing address:
  • Phone: 404-508-7700
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License NumberAPC008648
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: