Healthcare Provider Details

I. General information

NPI: 1942118088
Provider Name (Legal Business Name): JAELYN SHANTEL BLACKWELL
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/31/2026
Last Update Date: 08/31/2026
Certification Date: 08/31/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4405 MALL BLVD STE 145
UNION CITY GA
30291-2044
US

IV. Provider business mailing address

128 MEMORY LN
STOCKBRIDGE GA
30281-6263
US

V. Phone/Fax

Practice location:
  • Phone: 678-590-2739
  • Fax:
Mailing address:
  • Phone: 423-790-8809
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License NumberT004632
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: