Healthcare Provider Details

I. General information

NPI: 1750504353
Provider Name (Legal Business Name): JACQUELINE RUTH JOHNSON M.DIV.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/11/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4425 MEMORIAL DR
DECATUR GA
30032-1337
US

IV. Provider business mailing address

764 WYNBROOKE PKWY
STONE MOUNTAIN GA
30087-6322
US

V. Phone/Fax

Practice location:
  • Phone: 404-298-8383
  • Fax:
Mailing address:
  • Phone: 770-469-1225
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WA0400X
TaxonomyAddiction (Substance Use Disorder) Registered Nurse
License Number146319
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: