Healthcare Provider Details

I. General information

NPI: 1093624868
Provider Name (Legal Business Name): JERMAINE WOOLFOLK
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/05/2026
Last Update Date: 09/05/2026
Certification Date: 09/04/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

390 PARK HAVEN LN
TYRONE GA
30290-1723
US

IV. Provider business mailing address

390 PARK HAVEN LN
TYRONE GA
30290-1723
US

V. Phone/Fax

Practice location:
  • Phone: 404-822-5444
  • Fax:
Mailing address:
  • Phone: 404-822-5444
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code172A00000X
TaxonomyDriver
License Number050617374
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: