Healthcare Provider Details

I. General information

NPI: 1053606798
Provider Name (Legal Business Name): JAIME MELINDA WATKINS-GILLHAM
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/10/2011
Last Update Date: 03/02/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

130 CANAL ST BUILDING 400
POOLER GA
31322-4085
US

IV. Provider business mailing address

PO BOX 51322
BOWLING GREEN KY
42102-5622
US

V. Phone/Fax

Practice location:
  • Phone: 912-988-1444
  • Fax: 803-905-4431
Mailing address:
  • Phone: 270-777-9283
  • Fax: 270-777-9283

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number0-02-0531
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: