Healthcare Provider Details

I. General information

NPI: 1639040108
Provider Name (Legal Business Name): JARAH RACHEL TAVAREZ TORRES
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/16/2025
Last Update Date: 09/16/2025
Certification Date: 09/16/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1325 SATELLITE BLVD NW
SUWANEE GA
30024-4651
US

IV. Provider business mailing address

3130 HAMPTON BAY CV
BUFORD GA
30519-8628
US

V. Phone/Fax

Practice location:
  • Phone: 678-263-3080
  • Fax:
Mailing address:
  • Phone: 787-546-6186
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101Y00000X
TaxonomyCounselor
License NumberAPC0110637
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: