=====================================================
General NPI Number Information
=====================================================
NPI Number | 1447579925
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | JEFFERSON PSYCHOLOGICAL SOLUTIONS, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/24/2010
-----------------------------------------------------
Last Update Date | 05/24/2010
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3400 CHAPEL HILL RD SUITE 212
-----------------------------------------------------
City | DOUGLASVILLE
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30135-1739
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 678-741-5310
-----------------------------------------------------
Fax | 678-298-9899
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3400 CHAPEL HILL RD SUITE 212
-----------------------------------------------------
City | DOUGLASVILLE
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30135-1739
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 678-741-5310
-----------------------------------------------------
Fax | 678-298-9899
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | LICENSED PSYCHOLOGIST
-----------------------------------------------------
Name | DR. NINA N JEFFERSON
-----------------------------------------------------
Credential | PSY.D.
-----------------------------------------------------
Telephone | 678-741-5310
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 251S00000X
-----------------------------------------------------
Taxonomy Name | Community/Behavioral Health Agency
-----------------------------------------------------
License Number | PSY003323
-----------------------------------------------------
License Number State | GA
-----------------------------------------------------