Healthcare Provider Details

I. General information

NPI: 1356124747
Provider Name (Legal Business Name): JALYSSA AIKENS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/17/2023
Last Update Date: 06/05/2025
Certification Date: 06/05/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6385 MCGINNIS FERRY RD STE 2026385
JOHNS CREEK GA
30005-3621
US

IV. Provider business mailing address

7500 SAN FELIPE ST STE 990
HOUSTON TX
77063-1708
US

V. Phone/Fax

Practice location:
  • Phone: 470-508-9575
  • Fax: 470-508-9575
Mailing address:
  • Phone: 866-610-0580
  • Fax: 866-610-0580

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: