Healthcare Provider Details

I. General information

NPI: 1629694120
Provider Name (Legal Business Name): CLAYTON COUNTY JUVENILE JUSTICE FUND
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/19/2020
Last Update Date: 06/19/2020
Certification Date: 06/19/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1412 SOUTHLAKE PLAZA DR
MORROW GA
30260-1756
US

IV. Provider business mailing address

1412 SOUTHLAKE PLAZA DR
MORROW GA
30260-1756
US

V. Phone/Fax

Practice location:
  • Phone: 770-703-6675
  • Fax:
Mailing address:
  • Phone: 770-703-6675
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code104100000X
TaxonomySocial Worker
License Number
License Number State

VIII. Authorized Official

Name: DEBORAH STONE
Title or Position: EXECUTIVE DIRECTOR
Credential:
Phone: 734-392-4266