Healthcare Provider Details

I. General information

NPI: 1700924750
Provider Name (Legal Business Name): GA DEPARTMENT OF JUVENILE JUSTICE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/02/2007
Last Update Date: 09/11/2025
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3408 COVINGTON HWY
DECATUR GA
30032-1513
US

IV. Provider business mailing address

3408 COVINGTON HWY
DECATUR GA
30032-1513
US

V. Phone/Fax

Practice location:
  • Phone: 404-508-6610
  • Fax: 404-508-5091
Mailing address:
  • Phone: 404-508-6610
  • Fax: 404-508-5091

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code322D00000X
TaxonomyEmotionally Disturbed Childrens' Residential Treatment Facility
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code104100000X
TaxonomySocial Worker
License Number
License Number StateNULL

VIII. Authorized Official

Name: MS. SANDRA DEATON
Title or Position: FEDERAL PROGRAMS DIRECTOR
Credential:
Phone: 404-508-6610