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General NPI Number Information
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NPI Number | 1598328791
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Entity Type | Organization
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Legal Business Name | STRAIGHT STREET LIFE CENTER INC
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Dates
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Enumeration Date | 04/15/2019
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Last Update Date | 04/15/2019
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Provider Practice Location Address
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Address Line | 12461 VETERANS MEMORIAL
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City | DOUGLASVILLE
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State | GA
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Zip | 30134
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Country | US
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Telephone | 770-225-4701
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Fax |
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Provider Business Mailing Address
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Address Line | 12461 VETERANS MEMORIAL
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City | DOUGLASVILLE
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State | GA
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Zip | 30134
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Country | US
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Telephone | 770-225-4701
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Fax |
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Authorized Official
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Title or Position | EXECUTIVE DIRECTOR
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Name | MS. JESSICA L FRAZIER
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Credential | BA, CERTIFIED LIFE C
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Telephone | 404-951-3969
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 171M00000X
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Taxonomy Name | Case Manager/Care Coordinator
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 175T00000X
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Taxonomy Name | Peer Specialist
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License Number |
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License Number State |
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