Healthcare Provider Details

I. General information

NPI: 1962782722
Provider Name (Legal Business Name): JACKEY S MCKINNEY LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/25/2011
Last Update Date: 08/25/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

361 MANSFIELD WAY
STOCKBRIDGE GA
30281-1579
US

IV. Provider business mailing address

361 MANSFIELD WAY
STOCKBRIDGE GA
30281-1579
US

V. Phone/Fax

Practice location:
  • Phone: 404-275-2322
  • Fax:
Mailing address:
  • Phone: 404-275-2322
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberCSW004503
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: