Healthcare Provider Details

I. General information

NPI: 1134032345
Provider Name (Legal Business Name): JAQUON EDWARDS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/28/2026
Last Update Date: 09/28/2026
Certification Date: 09/28/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

899 POWERS FERRY RD SE APT E3
MARIETTA GA
30067-5767
US

IV. Provider business mailing address

899 POWERS FERRY RD SE APT E3
MARIETTA GA
30067-5767
US

V. Phone/Fax

Practice location:
  • Phone: 662-616-0595
  • Fax:
Mailing address:
  • Phone: 662-616-0595
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code374700000X
TaxonomyTechnician
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: