Healthcare Provider Details

I. General information

NPI: 1659848570
Provider Name (Legal Business Name): ANGELA GENEVA JENKINS-JACOBS DNP, PMHNP-BC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/29/2018
Last Update Date: 10/29/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

600 CELEBRATE LIFE PKWY
NEWNAN GA
30265-8001
US

IV. Provider business mailing address

2001 BLUEBIRD TRL
DOUGLAS GA
31533-3200
US

V. Phone/Fax

Practice location:
  • Phone: 678-723-1831
  • Fax:
Mailing address:
  • Phone: 912-650-1268
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License NumberRN104442
License Number StateGA
# 2
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License NumberRN104442
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: