Healthcare Provider Details

I. General information

NPI: 1376905117
Provider Name (Legal Business Name): ATHENA JACOWAY
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/22/2016
Last Update Date: 03/22/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2258 NORTHLAKE PKWY 390
TUCKER GA
30084-4019
US

IV. Provider business mailing address

1631 BRENTWOOD XING SE
CONYERS GA
30013-6300
US

V. Phone/Fax

Practice location:
  • Phone: 678-754-3507
  • Fax:
Mailing address:
  • Phone: 678-754-3507
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1744P3200X
TaxonomyProsthetics Case Management
License NumberCO078139
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: