Healthcare Provider Details

I. General information

NPI: 1184845513
Provider Name (Legal Business Name): JACQUELYN DENISE OWENS APRN, CNS/PMH-BC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/02/2007
Last Update Date: 11/02/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3188 ATLANTA RD SE
SMYRNA GA
30080-8256
US

IV. Provider business mailing address

3263 BOULDER BROOK DR
LITHONIA GA
30038-3004
US

V. Phone/Fax

Practice location:
  • Phone: 770-319-6000
  • Fax:
Mailing address:
  • Phone: 770-482-7184
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WP0808X
TaxonomyPsychiatric/Mental Health Registered Nurse
License NumberRN115796
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: