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General NPI Number Information
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NPI Number | 1336639889
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Entity Type | Individual
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Provider Name | JAMEQUA A STALLWORTH
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Gender | Female
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Dates
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Enumeration Date | 05/10/2018
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Last Update Date | 05/10/2018
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Provider Practice Location Address
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Address Line | 4460 CELEBRATION BLVD
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City | ACWORTH
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State | GA
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Zip | 30101-1105
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Country | US
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Telephone | 800-696-3904
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Fax |
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Provider Business Mailing Address
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Address Line | 128 HUNTERS POINTE CT
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City | VILLA RICA
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State | GA
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Zip | 30180-4408
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 235Z00000X
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Taxonomy Name | Speech-Language Pathologist
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License Number | SLP009469
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License Number State | GA
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