Healthcare Provider Details

I. General information

NPI: 1184408049
Provider Name (Legal Business Name): JIMMY ENOBABOR
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/22/2023
Last Update Date: 08/22/2023
Certification Date: 08/22/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

175 GWINNETT DR
LAWRENCEVILLE GA
30046-8444
US

IV. Provider business mailing address

244 COMMERCE DR
DECATUR GA
30030-1966
US

V. Phone/Fax

Practice location:
  • Phone: 678-209-2394
  • Fax:
Mailing address:
  • Phone: 817-987-3385
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: