Healthcare Provider Details

I. General information

NPI: 1952842064
Provider Name (Legal Business Name): MISS JILLIAN WHATLEY
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/09/2017
Last Update Date: 03/09/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7130 MOUNT ZION CIR SUITE 7
MORROW GA
30260-3308
US

IV. Provider business mailing address

1816 TEMPLE PARK DRIVE
LOGANVILLE GA
30052
US

V. Phone/Fax

Practice location:
  • Phone: 404-661-0867
  • Fax:
Mailing address:
  • Phone: 404-661-0867
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code102L00000X
TaxonomyPsychoanalyst
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code103TS0200X
TaxonomySchool Psychologist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: