Healthcare Provider Details

I. General information

NPI: 1992619613
Provider Name (Legal Business Name): JODI-ANN MASILO LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/30/2026
Last Update Date: 09/30/2026
Certification Date: 09/30/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

601 SEQUOIA CT
LOGANVILLE GA
30052-5600
US

IV. Provider business mailing address

601 SEQUOIA CT
LOGANVILLE GA
30052-5600
US

V. Phone/Fax

Practice location:
  • Phone: 678-900-7536
  • Fax:
Mailing address:
  • Phone: 678-900-7536
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: