Healthcare Provider Details

I. General information

NPI: 1386558609
Provider Name (Legal Business Name): JIREH SELENA TOBON
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/02/2026
Last Update Date: 10/02/2026
Certification Date: 10/02/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

450 FRANKLIN GATEWAY SE UNIT 160
MARIETTA GA
30067
US

IV. Provider business mailing address

131 WALTHALL AVE SE
MARIETTA GA
30060
US

V. Phone/Fax

Practice location:
  • Phone: 678-968-5019
  • Fax:
Mailing address:
  • Phone: 321-830-5459
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License NumberRBT-26-522747
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: