Healthcare Provider Details

I. General information

NPI: 1205070166
Provider Name (Legal Business Name): JASON T CAVIN
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/22/2009
Last Update Date: 01/19/2024
Certification Date: 01/17/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1301 SHILOH RD
KENNESAW GA
30144
US

IV. Provider business mailing address

1445 WOODMONT LN NW # 1098
ATLANTA GA
30318-2866
US

V. Phone/Fax

Practice location:
  • Phone: 866-278-3194
  • Fax: 866-278-3194
Mailing address:
  • Phone: 866-278-3194
  • Fax: 866-278-3194

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License NumberLPC006387
License Number StateGA
# 2
Primary TaxonomyN
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number1-12-12287
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: